European Observatory on Health Care System s
Portugal
I
Portugal
Health Care Systems in Transition
Portugal
Health Care Systems in Transition
The European Observatory on Health Care Systems is a partnership between the World Health Organization Regional Office for Europe, the Government of Norway, the Government of Spain, the European Investment Bank, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine
PLVS VLTR
IN TERNATIONAL BANK
FO R
R E
C O
N ST
RUCTION AND DEVELO P
M E
N T
WORLD BANK
1999
II
Portugal
European Observatory on Health Care Systems
AMS 5001890 CARE 04 01 01
Target 19 1999
Keywords
DELIVERY OF HEALTH CARE EVALUATION STUDIES FINANCING, HEALTH HEALTH CARE REFORM HEALTH SYSTEM PLANS – organization and administration PORTUGAL
©European Observatory on Health Care Systems 1999
This document may be freely reviewed or abstracted, but not for commercial purposes. For rights of reproduction, in part or in whole, application should be made to the Secretariat of the European Observatory on Health Care Systems, WHO Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark. The European Observatory on Health Care Systems welcomes such applications.
The designations employed and the presentation of the material in this document do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Care Systems or its participating organizations concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The names of countries or areas used in this document are those which were obtained at the time the original language edition of the document was prepared.
The views expressed in this document are those of the contributors and do not necessarily represent the decisions or the stated policy of the European Observatory on Health Care Systems or its participating organizations.
European Observatory on Health Care Systems WHO Regional Office for Europe
Government of Norway Government of Spain
European Investment Bank World Bank
London School of Economics and Political Science London School of Hygiene & Tropical Medicine
Target 19 – RESEARCH AND KNOWLEDGE FOR HEALTH By the year 2005, all Member States should have health research, information and communication systems that better support the acquisition, effective utilization, and dissemination of knowledge to support health for all. By the year 2005, all Member States should have health research, information and communication systems that better support the acquisition, effective utilization, and dissemination of knowledge to support health for all.
III
Portugal
Health Care Systems in Transition
Foreword ............................................................................................. v Acknowledgements .......................................................................... vii Introduction and historical background .......................................... 1
Introductory overview .................................................................... 1 Country background ....................................................................... 2 Historical background .................................................................... 7
Organizational structure and management ................................... 11 Organizational structure of the health care system ....................... 11 Planning, regulation and management of health services ............. 20
Health care finance and expenditure ............................................. 26 Main systems of finance and coverage ......................................... 26 Health care benefits ...................................................................... 29 Health care expenditure ................................................................ 30
Health care delivery system ............................................................ 37 Primary health care ....................................................................... 37 Public health services ................................................................... 44 Secondary and tertiary care .......................................................... 46 Social care .................................................................................... 54 Human resources and training ...................................................... 56 Pharmaceuticals and health care technology assessment ............. 64
Financial resource allocation .......................................................... 71 Third-party budget setting and resource allocation ...................... 71 Payment of hospitals .................................................................... 72 Payment of health centres ............................................................. 74 Payment of health care professionals ........................................... 74
Health care reforms ......................................................................... 79 Aims and objectives ..................................................................... 79 Reforms and legislation ................................................................ 80 Reform implementation ................................................................ 83
Conclusions ....................................................................................... 85
Bibliography ..................................................................................... 89
Contents
IV
Portugal
European Observatory on Health Care Systems
V
Portugal
Health Care Systems in Transition
Foreword
The Health Care Systems in Transition (HiT) profiles are country-based reports that provide an analytical description of each health care system and of reform initiatives in progress or under development. The HiTs
are a key element that underpins the work of the European Observatory on Health Care Systems.
The Observatory is a unique undertaking that brings together WHO Regional Office for Europe, the Governments of Norway and Spain, the European Investment Bank, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. This partnership supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of the dynamics of health care systems in Europe.
The aim of the HiT initiative is to provide relevant comparative informa- tion to support policy-makers and analysts in the development of health care systems and reforms in the countries of Europe and beyond. The HiT profiles are building blocks that can be used to:
• learn in detail about different approaches to the financing, organization and delivery of health care services;
• describe accurately the process and content of health care reform programmes and their implementation;
• highlight common challenges and areas that require more in-depth analysis;
• 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 the different countries of the European Region.
The HiT profiles are produced by country experts in collaboration with the research directors and staff of the European Observatory on Health Care Systems. In order to maximize comparability between countries, a standard template and questionnaire have been used. These provide detailed guidelines
VI
Portugal
European Observatory on Health Care Systems
and specific questions, definitions and examples to assist in the process of developing a HiT. Quantitative data on health services are based on a number of different sources in particular the WHO Regional Office for Europe health for all database, Organisation for Economic Cooperation and Development (OECD) health data and the World Bank.
Compiling the HiT profiles poses a number of methodological problems. In many countries, there is relatively little information available on the health care system and the impact of reforms. Most of the information in the HiTs is based on material submitted by individual experts in the respective countries, which is externally reviewed by experts in the field. Nonetheless, some statements and judgements may be coloured by personal interpretation. In addition, the absence of a single agreed terminology to cover the wide diversity of systems in the European Region means that variations in understanding and interpretation may occur. A set of common definitions has been developed in an attempt to overcome this, but some discrepancies may persist. These problems are inherent in any attempt to study health care systems on a comparative basis.
The HiT profiles provide a source of descriptive, up-to-date and comparative information on health care systems, which it is hoped will enable policy-makers to learn from key experiences relevant to their own national situation. They also constitute a comprehensive information source on which to base more in- depth comparative analysis of reforms. This series is an ongoing initiative. It is being extended to cover all the countries of Europe and material will be updated at regular intervals, allowing reforms to be monitored in the longer term. HiTs are also available on the Observatory’s website at http://www.observatory.dk.
VII
Portugal
Health Care Systems in Transition
Acknowledgements
The Health care system in transition report on Portugal was written by Anna Dixon, (European Observatory on Health Care Systems) in collaboration with a Working Group led by Professor Vasco Reis
(Adviser in the General Directorate of Health, Ministry of Health and Professor in the National School of Public Health). The Research Director for the Portugal HiT was Elias Mossialos, who edited the HiT.
The Working Group was composed of Ana Lisette Santos Oliveira, Trainee Senior Officer (Statistics) in the General Directorate of Health (Ministry of Health), Avelina Pereira, Medical Doctor (Ministry of Health), Luís Filipe Salles Camejo, Senior Officer in the General Directorate of Health (Ministry of Health), Mª do Rosário Sepúlveda, Economist and Hospital Administrator (Ministry of Health), Cecília Lopes, Senior Officer in the General Directorate of Health (Ministry of Health) and project coordinator, and Vasco Pinto Reis, Adviser in the General Directorate of Health (Ministry of Health), Professor in the National School of Public Health and project director, editor and liaison.
The European Observatory on Health Care Systems is grateful to Predro Pita Barros (Faculty of Economics, New University of Lisbon) for reviewing the report and for the support of Constantino Sakellarides (Director-General for Health) and the Ministry of Health.
The current series of the Health Care Systems in Transition profiles has been prepared by the research directors and staff of the European Observatory on Health Care Systems. The European Observatory on Health Care Systems is a partnership between the WHO Regional Office for Europe, the Govern- ment of Norway, the Government of Spain, the European Investment Bank, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.
Observatory team working on the HiT profiles is led by Josep Figueras, Head of the Secretariat and the research directors Martin McKee, Elias Mossialos and Richard Saltman. Technical coordination is by Suszy Lessof.
VIII
Portugal
European Observatory on Health Care Systems
The series editors are Anna Dixon, Judith Healy, Elizabeth Kerr and Suszy Lessof. Administrative support, design and production of the HiTs has been undertaken by a team led by Phyllis Dahl and comprising Myriam Andersen, Sue Gammerman and Anna Maresso. 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 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 (CEE) countries. Thanks are also due to national statistical offices which have provided national data.
1
Portugal
Health Care Systems in Transition
Introduction and historical background
Introductory overview
The Health Care systems in transition profile of Portugal gives a broad overview of the Portuguese health care system, its organization, financing and delivery. It describes in detail some of the reforms which have taken
place in recent years and the changes which the system is presently under- going. Following a general introduction to the country and its people the report describes the historical development of health care services in Portugal since the eighteenth century up to the present day. The section on Organizational structure and management provides a description of the administrative bodies which make up the health care system of Portugal. It also introduces some of the other institutions and bodies which operate in the areas of health care financing, purchasing and provision of services both within the National Health Service and the private sector. Planning, regulation and management looks at the mechanisms for capital, human resource and expenditure planning and the bodies responsible for the regulation of services and pharmaceuticals. Pharma- ceutical regulation and policy are discussed in more detail in the final part of the section on Health care delivery system.
There are well-documented difficulties in obtaining reliable comparative data, particularly on health care expenditure. The section on Health care finance and expenditure attempts to bring together available national and international data on this subject and provide a brief analysis of the trends. It firstly considers the multiple sources of funding for health care including out-of-pocket payments and voluntary health insurance. It goes on to describe the levels of coverage and benefits offered. Finally it presents and analyses health expenditure data.
The health care services and provision offered in Portugal and the organi- zation of the delivery of health care are described in the section on Health care delivery system. Primary, secondary and tertiary medical care services are
2
Portugal
European Observatory on Health Care Systems
described as well as public health services and social care services. A separate part on human resources and training describes issues relating to the number and type of health personnel in the workforce, their distribution and the training requirements. Finally, this section concludes with a description of pharma- ceutical and technology assessment including the regulation of medical equipment (standards, quantity and distribution), approval of drug products, drug pricing and control of pharmaceutical sales.
The section on Financial resource allocation describes the flow of money through the system, from the population/patient through the various funding agencies to providers. Changes in the mechanisms for funding allocations from the centre to regional authorities are described, as is the new model of purchasing being introduced for hospital services. The changes to the methods of funding hospital services, primary care services and the payment of health care profes- sionals are also described.
Much of this report is descriptive with limited analysis of data. As well as describing the current system it indicates the pressures for change, the nature of planned reforms, the process of implementation and possible outcomes. The section on Health care reforms brings together this information by highlighting the general pressures for change within the system and the barriers to change. It also presents a chronology of health legislation which has been enacted. Finally it describes the process of implementation and the extent to which reforms have achieved their stated objectives.
Country background
Physical and human geography
Portugal is part of the Iberian Peninsula which lies in the south-west of Europe. The archipelagos of Azores (nine islands) and Madeira (two islands) in the Atlantic Ocean also form part of Portugal. The mainland is 91.9 thousand km² with 832 km of Atlantic coastline and an inland border with Spain that stretches for 1215 km. It is one of Europe’s smallest countries, measuring 560 km north to south and only 220 km from east to west. Portugal’s two main cities are Lisbon (resident population 1 834 000 in 1995) and Porto (population 1 188 000 in 1995).
3
Portugal
Health Care Systems in Transition
1 The maps presented in this document do not imply the expression of any opinion whatsoever on the part of the Secretariat of the European Observatory on Health Care Systems or its partners concerning the legal status of any country, territory, city or area or of its authorities or concerning the delimitations of its frontiers or boundaries.
Spain
Spain
North Atlantic Ocean
Golfo de Cádiz
Viana do Castelo
Braga
Porto
Ave iro
Co im bra Covilhã
Porta legre
L ISBO N Barre iro
Setúba l
Be ja
Faro
Azores and M adeira Is lands are no t shown
0 25 5 0 km
0 25 50 m i
Fig 1. Map of Portugal1
The River Tejo, which rises in Central Spain, divides the country into two distinct geographical areas. The northern and central regions are characterized by rivers, valleys, forests and mountains – the highest range is the Serra da Estrela, peaking at Torre (1993 m). The south is less populated and, apart from the rocky backdrop of the Algarve, much flatter and drier.
4
Portugal
European Observatory on Health Care Systems
Portugal has a temperate climate influenced by the Atlantic Ocean. However, it experiences considerable variations in climate; the southern region of the Algarve can experience extremely high temperatures in midsummer whilst, during winter, the north receives plenty of rain and temperatures can be chilly, with snowfall common in the mountains, particularly in the Serra da Estrela range. As a result, the natural flora is very varied. It is possible to find not only species from western Europe, but also those characteristic of Mediterranean countries.
The total population of Portugal was 9 893 000 (mid-year estimate 1997) (51), which represents a small decrease of 1.9% over the last decade. The demographic profile follows that of other west European countries with an increase in life expectancy at birth from 71.15 years in 1980 to 74.9 years in 1996 (51). The median age of the population has risen from 31 years old to 36 years old over a ten-year period 1986–1996, whilst the dependency ratio has fallen from 79.7 in 1984 to 68.3 in 1994 (based on the relation of the population under 20 and over 65 years of age to the 20–64 year olds) (32). Demographic changes have followed an improvement in the socioeconomic conditions.
Economy
Economic growth which began in early 1994 has gathered pace and real GDP growth increased to an estimated 3.5% in 1997. This growth is as a result of stronger domestic demand and new export capacity (31). The GDP per capita was 1.7 million Escudos or US $PPP 13 672 or Euros PPP 12 783 in 1997 (32). The inflation rate was just above 2% in 1997, down from 3.2% in 1996 (31). Unemployment has fallen slightly from 7.3% of the total population in 1996 to 6.9% in 1997; however, it is still considerably higher than the rate of 5.5% in 1993 (31).
Table 1 shows the relative importance of different industrial sectors in the Portuguese economy. The main industries are textiles, tourism and agriculture. The textiles sector is the only sector of the manufacturing industry which has sustained its share of the total workforce whilst service industries connected to tourism have seen an increase from 13.4% to 17.3% of total employment (1980–1993).
Political and administrative structure
Portugal has been a constitutional democratic republic since 1974, when the revolution put an end to the 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 elected by direct universal suffrage.
5
Portugal
Health Care Systems in Transition
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.
Portugal’s administrative system comprises 18 districts and 2 autonomous regions (the islands of Azores and Madeira). The islands have their own political and administrative structures, although executive power remains with the central government. The President appoints a Minister of the Republic to represent the Republic in each of the autonomous regions. These Ministers are proposed by the national government.
The districts are further divided into municipalities and boroughs. The municipalities have their own level of elected government.
Macau is a small territory situated to the south of China which formally has been under Portuguese sovereignty since 1887. The Sino-Portuguese Joint Declaration on the Question of Macau, which was signed in April 1987, declares that China will resume sovereignty over the territory on 20 December 1999.
Health indicators
The health of the Portuguese population can be summarized as follows:
• life expectancy at birth has continued to develop favourably in the past twenty years (see Table 2);
• indicators of child health are improving, and are near the average European rate. The infant mortality rate decreased fivefold between 1970 and 1990, the perinatal mortality rate by 66%;
Table 1. Structure of the economy according to category of industry (% share of GDP and % of total employment), 1980 and 1993
% share GDP % total employment
1980 1993 1980 1993
Agriculture, forestry and fishing 10.3 3.7 27.2 14.2 Manufacturing 31.0 23.9 25.1 23.4 Electricity, gas and water 2.1 4.2 1.9 0.9 Construction 7.1 5.3 4.5 4.9 Services 49.5 61.9 36.8 51.1
Source: OECD Economic Surveys 1997–1998 Portugal (1998) (31).
6
Portugal
European Observatory on Health Care Systems
• there have been improvements in women’s health – female mortality from all cancers has been declining since the early 1970s.
Improvements in health status of the Portuguese population are connected to a general improvement in economic and social conditions (e.g. housing, education, sanitation, communication and transport infrastructures), as well as to the increase in human, material and financial resources devoted to health care.
Despite the overall improvement in living standards, there are inequalities between the regions, and probably between social classes. These disparities are evident in the variation of some health indicators, e.g. mortality rates and infant mortality rates, as well as in inequalities of access, e.g. the ratio of in- habitants to hospitals and the ratio of inhabitants to health professionals.
Table 2. Health indicators for Portugal 1970–1996
1970 1975 1980 1985 1990 1995 1996
Infant mortality, deaths per 1000 live births 55.1 38.9 24.3 17.8 11 7.4 6.9
Perinatal mortality, deaths per 1000 total births 37 31.3 23.9 19.7 12.6 9 8.4
Life expectancy in years at birth (females) 71 72.6 – 76.7 77.9 78.2 78.5
Life expectancy in years at birth (males) 65.3 65.2 67.7 69.7 70.9 71 71.2
Source: OECD health data 98 (32).
The leading causes of death are shown in Table 3. After diseases of the circulatory system which account for 29.59% of all deaths, cancers represent five out of the eleven leading causes of death. For diseases caused by lifestyle or behaviour, trends are not so clear; however, the mortality from road traffic accidents is the highest in Europe.
Table 3. Leading causes of death in Portugal 1998
Cause of death Percentage of Cause of death Percentage of all deaths all deaths
Cerebrovascular disorders 20.86 Chronic liver disease 2.50 Ischaemic heart disease 8.73 Motor vehicle accidents 1.92 Pneumonia 3.77 Colon cancer 1.80 Diabetes mellitus 3.03 Prostate cancer 1.59 Cancers of the respiratory tract 2.52 Breast cancer 1.4 Stomach cancer 2.50
Source: Division of Epidemiology, General Directorate of Health, Ministry of Health, Portugal 1998 (3).
7
Portugal
Health Care Systems in Transition
Historical background
Portugal’s health care system is complex as a result of its historical develop- ment. In order to examine the existing system it is important to recognize some of the main factors which have influenced the development of the Portuguese health care system to date.
Prior to the eighteenth century, health care was provided only for the poor by the hospitals of the religious charities called Misericórdias2. During the eighteenth century, the state established a limited number of teaching hospitals and public hospitals to supplement the charitable provision. This was further extended in 1860 with the appointment of salaried municipal doctors who pro- vided curative services to the poor.
The development of public health services did not begin until 1901. The first act of public health legislation 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 tuber- culosis, 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 to the employed population and their dependants through social security and sickness funds. This social welfare system was financed by compulsory contributions, shared between employees and employers, and provided out-of-hospital curative services, free at the point of use. Cover was limited to industrial workers in the first instance. Other sectors of the workforce and their dependants were added through extensions to social security coverage in 1959, 1965, 1971 and 1978.
Primary health care was not the subject of public intervention until the 1960s when new powers were established for its financing and organization.
Despite the efforts made prior to 1970, the following major problems still existed:
• asymmetry in the geographic distribution of health facilities and human resources with concentration in urban areas;
• poor sanitation and inadequate population coverage;
• centralized decision-making;
2 Misericórdias still exist in Portugal but no longer provide acute hospital care.
8
Portugal
European Observatory on Health Care Systems
• no linkage or coordination among existing facilities and providers, and little evaluation;
• multiple sources of financing and a disparity of benefits between different population groups;
• a discrepancy between the intentions of legislation and policy and actual provision of health services;
• low remuneration of health professionals.
Up until 1979 and the establishment of the National Health Service, the Portuguese government had traditionally left the responsibility for paying for health care to the individual patient and his or her family. Care of the poor was the responsibility of the charity hospitals and out-of-hospital care remained the responsibility of the Department of Social Welfare. The government only took full responsibility for the costs of health care for civil servants. Otherwise the government limited provision for the general population to preventive care, maternal and child health, the control of infectious diseases and mental health.
The move towards greater public provision of health care and a commit- ment to universality was embodied in legislation passed in 1971. This law, although never implemented fully, gave priority to prevention over cure and sought to integrate health policy in the context of wider social policy, i.e. to include protection of the family and disabled persons and other social welfare activities connected with health. After the revolution of 1974, a process of health services “nationalization” began which culminated in the establishment of the NHS.
Firstly in 1974, district and central hospitals owned by the religious charities were taken over by government. Local hospitals followed in 1975 and were integrated with existing health services. Finally in 1977, over 2000 medical units or health posts situated throughout the country were taken over by the government. These had previously been operated under the social welfare system for the exclusive use of social welfare beneficiaries and their families. The principle of a citizen’s right to health was embodied in the Portuguese constitution as early as 1976 and was to be delivered through a “National Health Service which was universal, comprehensive and free of charge”. 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. It brought together public health services and the health services provided by social welfare leaving the general social security system to provide cash benefits and other social services (e.g. for the elderly and children).
9
Portugal
Health Care Systems in Transition
So by 1979 legislation had been introduced to establish:
• the right of all citizens to health protection;
• a guaranteed right to health care that was “universal, comprehensive and free of charge” through the NHS;
• access to the NHS for all citizens regardless of economic and social back- ground;
• the provision of integrated health care including health promotion, disease surveillance and prevention;
• a tax-financed system of coverage in the form of the NHS for which the government was responsible. (Only when health care could not be provided through the NHS would services provided outside the NHS be covered).
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 and religious charities, some aspects of the pre- 1970s system persisted. In particular the health subsystems (from the Portuguese subsistemas) continued to operate which covered a variety of public and private employees. These schemes were offering better services and greater choice of provider than would be available under the NHS. 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 principles, but was implemented locally by the regional govern- ments who retained some flexibility.
At the beginning of the 1990s the health care system in Portugal continued to face problems such as:
• an inadequate supply of public ambulatory services, resulting in an increase in attendance at hospital emergency departments;
• dissatisfaction of consumers and professionals with public services;
• a major increase in health expenditure and extreme difficulties with cost control;
• lack of responsiveness to the needs of some vulnerable groups, such as the elderly, drug addicts, alcoholics, and AIDS patients;
• difficulty in reducing mortality due to traffic accidents and lifestyle diseases.
Discussion of how these problems are being addressed through further reforms is included in each section of this report. The relevant legislation and reforms are discussed in detail in the section Health care reforms.
10
Portugal
European Observatory on Health Care Systems
11
Portugal
Health Care Systems in Transition
Organizational structure and management
The Portuguese health care system is characterized by three co-existing systems of health care coverage: the National Health Service (NHS), special insurance schemes for certain professions, and voluntary private
health insurance schemes. In this section the various bodies, organizations and institutions which make up the health care system will be outlined. Firstly the internal structure of the Ministry of Health will be described. Then other national and regional government authorities with a role in health care will be examined. Finally the private sector and the health subsystems, including the functions and responsibilities each has within the health care system, will be reviewed.
Ministry of Health
The central government, through the Ministry of Health, holds the main responsibility for the regulation, organization and direction of the health care system as a whole.
The Ministry of Health is responsible for developing health policy and over- seeing and evaluating its implementation. It is also responsible for the coordi- nation of health-related activities of other Ministries, such as social services, education, employment, sport, the environment, the economy, housing and town planning. The core function of the Ministry is the regulation, planning and management of the National Health Service (NHS). Many of the planning, regulation and management functions are in the hands of the Minister of Health. The Secretary of State is a junior Minister and has responsibility for the first level of coordination.
The Ministry is made up of five Directorates and seven Institutes. These are:
Organizational structure of the health care system
12
Portugal
European Observatory on Health Care Systems
The General-Secretariat of the Ministry of Health 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 General Directorate of Health (GDH) Regulates, directs, coordinates and supervises all health promotion, disease prevention and health care activities, institutions and services, whether or not they are integrated into the NHS.
The General Inspectorate of Health Performs the disciplinary and audit function for the National Health Service in collaboration with GDH and audits NHS institutions and services.
The General Directorate of Health Infrastructures and Equipment Assesses, regulates, plans and coordinates the procurement of equipment and provides technical support for the programme of NHS building work. Supported by regional directorates.
The Department of Human Resources Regulates, directs and evaluates human resource activities for the NHS, namely professional education and practice. Directly oversees schools for the training of nurses and technical staff working in health.
The National Institutes are as follows: The National Institute of Pharmaceuticals and Medicine The National Institute for Medical Emergencies The Portuguese Blood Institute The Service for Drug Addiction Prevention and Treatment The Institute of Financial Management and Informatics The Social Services for Health Personnel The National Institute of Health, Doctor Ricardo Jorge3
There are also three vertical programmes run by national bodies attached to the Ministry of Health: the National Prevention Council Against Tobacco Consumption, the National Committee on AIDS and the National Council of Oncology.
Legal provision is made for a National Health Council, which is a consul- tative body for the Ministry of Health. Its function, in theory, is to represent all those concerned with the performance of health care providers: patients; health care employees; government departments in charge of health-related activities
3 This institute promotes scientific research in the field of health and is the main reference laboratory for the public health sector. It also functions as the national observatory and surveillance centre on health.
13
Portugal
Health Care Systems in Transition
and other bodies. In reality the Council has never met and does not function, possibly because the Ministry and its departments feel threatened by a potential loss of power to the Council.
Other Ministries
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 also determines the budget for the NHS based on a submission from the Ministry of Health. See the section on Third-party budget setting and resource allocation for more information about this process.
Ministry of Employment and Social Solidarity: This Ministry is responsible for social benefits, such as pensions, unemploy- ment benefit and incapacity benefit. In 1995, 9.5% of GDP was allocated to social security. Of this 73% was spent on pensions, 11.3% on unemployment benefits and 6.0% on disability benefits. The interface and collaboration between this Ministry and 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 care for the elderly.
Ministry of Education:
The Ministry of Education is responsible for undergraduate medical education and for academic degrees such as Masters and PhDs. Specialty training, however, is the joint responsibility of the Medical Association and the Ministry of Health.
Regional health administrations (RHAs)
The Portuguese NHS, though centrally financed by the Ministry of Health, has a strong regional structure of health administrations. There are five regional health administrations in Portugal: North, Centre, Lisbon & Tagus Valley, Alentejo and the Algarve. In each region a regional health administration board, accountable to the Minister of Health, manages the NHS.
The regional health administrations (RHAs) are responsible for the local implementation of national health policy objectives. They coordinate all levels of health care and allocate resources to hospitals and health centres. 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
14
Portugal
European Observatory on Health Care Systems
strategic health administration, coordination of all aspects of health care provision, management of hospitals and health centres, establishment of agree- ments and protocols with private bodies, and liaison with central bodies, Misericórdias and other private non-profit bodies, and municipal councils.
The regional health administration boards have specific duties to:
• draw up regional plans and budgets, and to monitor and be accountable for them;
• guide, coordinate and monitor NHS management at regional level;
• represent the NHS in and out of court;
• regulate the supply of health providers in the region and guide, coordinate and monitor their performance;
• contract with the private sector to provide health care for NHS beneficiaries in each region, subject to national agreements on this matter;
• continuously evaluate the outcomes and outputs attained;
• coordinate transportation of patients within both the public and private sectors.
Regional health administrations are subdivided into eighteen sub-regions each with a sub-regional coordinator.
North: main offices in Porto, covers the administrative districts of Braga, Bragança, Porto, Viana do Castelo and Vila Real;
Centre: main offices in Coimbra, covers Aveiro, Castelo Branco, Coimbra, Guarda, Leiria and Viseu;
Lisbon and Tagus Valley: main offices in Lisbon, covers Lisbon, Santarém and Setúbal;
Alentejo: main offices in Évora, covers Beja, Évora and Portalegre;
Algarve: main offices in Faro, covers the district of Faro.
Since 1998 each regional health administration (RHA) has established a regional agency (RA) within it. The RA is an autonomous part of the RHA with responsibility for contracting with hospitals, health centres and independent groups of doctors. Its two main functions are to increase citizen participation in health decision-making and to develop the separation of purchasing and provider functions.
Local government
Below the region and sub-region are the municipalities. Health issues at this level are under the jurisdiction of the Municipal Health Commission. For the
15
Portugal
Health Care Systems in Transition
Fig 2. Organizational chart of Ministry of Health structure
Minister of Health
Central
District
Specialized
National Prevention Council Against
Tobacco ConsumptionNational Health Council1
National Council of Oncology
National Committee on AIDS
General-Secretariat
General Inspectorate
General Directorate
Institute of Medical Genetics
Health Centres
Regional Health Administrations
Social Services for Health Personnel
Senior Nursing Schools
Technical Health Service
Schools Department of Human Resources
Histocompatibility centres (Centre-North-
South)
Delegations Coimbra - Porto
Service for Drug Addiction
Prevention and Treatment
Institute of Financial Management and
Informatics
General Clinical Institute
Regional Centres for the rehabilitation of
alcoholics
Mental Health Centres
General Directorate of Health Infrastructures
and Equipment
Portuguese Blood Institute
National Institute for Medical Emergencies
Delegations Coimbra - Porto
Secretary of State
Regional Directorate for
Health Infrastructures and Equipment
Ophthalmology Centre Dr. Gama Pinto
National Institute of Health
Dr. Ricardo Jorge
National Institute of Pharmaceuticals
and Medicine
Regional Centres Coimbra-Lisbon-
Porto
Hospitals
Regional Centres
N A
T IO
N A
L H
E A
LT H
S E
R V
IC E
1 The National Health Council is not a functioning body
16
Portugal
European Observatory on Health Care Systems
purposes of health care provision, boundaries are based on natural communities rather than administrative areas, i.e. some communities may be included in neighbouring municipalities. This ensures that services are provided more quickly and easily. In some cases the larger urban communities have their own system of organization of health care in order to meet the particular needs of the population. There are a number of initiatives being undertaken in coopera- tion 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.
Health subsystems
The historical remnants of the social welfare system 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) and this term will be used throughout the report.
In addition to the cover provided by the NHS, about 25% of the population4
are covered by the health subsystems. Health care is provided either directly or by contract with private or public health care providers (in some cases by a combination of both). Access is generally limited to members of a specific profession and their families.
The main funds operating in the public and private sector are:
• ADSE (Assistência a Doença dos Servidores do Estado) for civil servants;
• ADM (Assistência na Doenca aos Militares) for military personnel (including administrative staff). It has three separate bodies: ADME (Assistencia na Doenca aos Militares do Exercito) for the army, ADMA (Assistencia na Doenca aos Militares da Armada) for the Navy and ADMFA (Assistencia na Doenca aos Militares da Forca Aerea) for the Air Force;
• IOS-CTT (Instituto das Obras Sociais dos CTT) for post office workers;
• PT-ACS (Portugal Telecom – Associacao de Cuidados de Saude) for the employees of the public telecom operator;
• SAMS (Servicos de Assistência Médico-Social) for bank employees and associated insurance workers. It has three regional branches: Central, North, South and Islands;
• SSINCM (Servicos Sociais da Imprensa Nacional Casa da Moeda) for the workers at the national mint;
4 There is no exact figure for the number of people covered by the subsystems as double-counting may occur due to people belonging to more than one subsystem.
17
Portugal
Health Care Systems in Transition
• SSMJ (Servicos Sociais do Ministerio da Justica) for workers of the Ministry of Justice;
• SSCGD (Servicos Sociais da Caixa Geral de Depositos) for the workers of the main public bank.
There are also a few additional smaller funds. Most health subsystems are members of the National Association of Health Subsystems.
The largest fund ADSE covers 15% of the population and is controlled by the Ministry of Finance. It includes amongst its members all employees of the NHS, creating a perverse situation where medical professionals and other pro- fessionals are entitled to supplementary care that is not available to patients within the NHS. Some of the funds are associated with and run by trade unions and managed by boards of elected members.
Most of the schemes are compulsory for employees but do not preclude the beneficiary from seeking services directly from the NHS. However, the health subsystems do usually give more freedom of choice to the beneficiaries than they may otherwise have within the statutory system. Whilst users are free to purchase services wherever they choose, most use the private sector for ambu- latory care and the NHS for non-elective surgical interventions. A few schemes provide health services directly, in which case members will be expected to seek care from these doctors in the first instance.
Private sector
Private health care providers mainly fulfil a supplementary role to the NHS rather than providing an alternative to it. Most private sector activity continued to prosper despite the establishment of the NHS and now mainly provides diagnostic, therapeutic and dental services as well as some ambulatory consul- tations, rehabilitation and psychiatric care services. The key institutions are private practitioners, Misericórdias, and private hospitals, clinics and facilities.
The level of activity in the private sector compared to the public sector can be seen in Table 4. The majority of specialist consultations take place in the private sector whereas the public sector provides the overwhelming majority of general consultations.5 Overall the private sector accounts for 30% of all medical consultations.
5 Figures are based on responses to a National Health Survey question about the last visit to a doctor. This included both the type of visit, i.e. to a GPs or several specialities, and where the consultation took place, i.e. health centres, public hospitals, private clinics, etc. No adjustment was made for possible differences in age, sex or place of residence between the survey respondents and the general population.
18
Portugal
European Observatory on Health Care Systems
Misericórdias Misericórdias are independent charitable institutions6.
They currently operate very few hospitals, despite their historical role as one of the main providers of health care. The hospitals currently operated by Misericórdias provide services which include orthopaedics, plastic surgery, internal medicine and complementary therapies. There are usually no acute or emergency services in these hospitals. There has been a shift in focus of the work of Misericórdias and other religious organizations from health to social care. They are now the main providers of social care and psychiatric and rehabili- tation services in Portugal.
Private hospitals, and other privately provided services In 1996, 42% of hospitals in Portugal were privately owned. Of these almost half belonged to for-profit organizations. However only 22.5% of the total bed stock is privately owned. See the section on Secondary and tertiary care for more information about hospitals and hospital beds in the public and private sectors. One of the main areas of private activity is in the provision of diagnostic tests and examinations: pathology, blood tests and X-rays are mostly provided privately. In addition treatment by physiotherapists and dental care are largely provided by the private sector.
Private health insurance companies On the financing side, the main private actors are the private health insurance companies. Voluntary health insurance (VHI) was introduced in 1978. Initially only group policies were offered but since 1982 individual policies also have been offered. Approximately 10% of the population were covered by private insurance in 1998. Most policies are in the form of group insurance provided by the employer: less than 10% of people with private health insurance have individual policies.
Table 4. Percentage of medical consultations in the public and private sector in Portugal 1995/1996
General Specialist Total
Public 58.5 11.1 69.6
Private 14.1 16.3 30.4
Source: (1) based on the Health Interview Survey 1995/1996 (8).
6 Misericórdias Lisbon is an exception; it is a public enterprise which means that the Board is nominated jointly by the Ministry of Health and the Ministry of Employment and Social Solidarity rather than elected by members.
19
Portugal
Health Care Systems in Transition
Professional associations and unions
There are three main representative organizations for doctors: the Medical Association and two trade unions. The Medical Association represents the strong corporate interests of the medical profession and membership is obligatory. The Association’s functions include:
• accreditation and granting of licences to practise;
• accreditation and certification of specialist training (joint responsibility with the Ministry of Health) (see the section on Human Resources and Training);
• enforcing the disciplinary code with powers to censure doctors; however, few doctors are actually censured in practice.
An equivalent body for nurses (the Portuguese Nurses’ Association) was established in 1998 with similar powers to the Medical Association. There is also a national association for dentists, which maintains the dental register and receives and investigates complaints against dentists with the power to suspend (though this has never happened).
The representative body for the pharmaceutical profession is the National Association of Pharmacists, for which membership is compulsory. It covers pharmacists and others licensed to work in industry, laboratories and enterprises and is the legal representative of people with a degree in pharmaceutical sciences. In the same way as the Medical Association, it has regulatory and disciplinary powers.
The National Association of Pharmacists also has a powerful corporate role. It operates as a fund which handles the majority of pharmaceutical pay- ments between the NHS and the pharmacists. As mentioned before, almost 95% of pharmacists are members of the National Association of Pharmacists; however some choose to remain independent. The Association offers incen- tives in order to maintain membership rates such as computers, software, continuous education and other services which are of benefit to the pharmacist.
Public and consumer groups
There is currently no official organization which advocates on behalf of patients in Portugal. There are a number of quite active disease-based advocacy groups such as those based around diabetics, haemophilia and HIV and AIDS. These are narrow interest groups which usually promote the allocation of more resources for the care and treatment of patients in that particular disease group. The development of mechanisms for giving citizens a voice about their health care is being developed by regional agencies (RAs) as part of their remit. A citizens’ representative, who will act as an intermediary between the RHA and
20
Portugal
European Observatory on Health Care Systems
the people, will be involved in the development of local health systems (see section on Primary health care). The citizen representative will be chosen either by the local municipal council or a consumer group, where the latter exist.
There are formal mechanisms for consumers to make complaints. In every public medical institution there is an office where patients can complain about any aspect of the NHS (called the Users’ Office). All complaints are dealt with through the Users’ Office and may be referred, in extreme cases where there is evidence of medical negligence, to the Medical Association in order for the case to be pursued. Patients are free to write directly to the regional coordina- tors or the Minister of Health or to pursue their case through the courts. This is, of course, expensive and few people do so. On the whole there are few com- plaints. The majority relate to organizational aspects such as waiting times or aspects of the service rather than technical matters regarding a specific treat- ment or intervention.
More mechanisms are being introduced to encourage citizens’ participa- tion in health; to increase patients’ trust in the health system, to encourage the population to take responsibility for its own health and obtain better quality and more appropriate care for users.
Planning, regulation and management of health services
The boundaries between the main functions in the system – planning, regula- tion, financing and management – overlap, due to the integrated nature of health provision, i.e. the government is both the main provider and third-party payer.
Planning
The Portuguese Constitution stipulates that the economic and social organization of the country must be guided, coordinated and disciplined by a national plan. Thus, planning is at the heart of the system of government. The national plan must ensure, for example, the harmonious development of different sectors and regions, the efficient use of productive resources, and the equitable division of resources amongst the population and between regions.
There are central, regional and sectoral planning bodies. Central planning for health is mainly carried out by the General Directorate of Health, based on plans submitted by the regional health administration boards (RHAs).
21
Portugal
Health Care Systems in Transition
As the NHS does not have its own central administration, most of the planning, regulation and management functions are carried out by the Ministry of Health. The Director General of Health has no direct hierarchical authority over the RHAs but is able to make suggestions and advise. Most RHAs will try to follow national policies but there is no obligation to do so. Consequently each region pursues national policies at a different pace.
Capital planning A separate central investment plan governs capital outlays within the NHS. Capital investment is the responsibility of the General Directorate of Health. Most of the investment is provided internally by the Portuguese state budget through the Central Administration’s Investment and Development Plan (PIDDAC). There has also been joint funding of hospital and health centre developments with the European Union through the European Regional Development Fund (ERDF).
Legislation in 1988 gave the Ministry of Health total control over the procurement and installation of high-technology equipment in the NHS and private sector. The legal guidelines for installing heavy equipment established ratios of equipment per inhabitant. In 1995 new legislation was passed which abolished the population ratios. However, the principle of prior authorization by the Ministry of Health for equipment within the NHS was retained.
In 1998 Portugal published a national list of health equipment (21) which describes the distribution of specific items of equipment and services through- out Portugal. It gives information regarding such things as the regional varia- tions in the number of items of equipment, the numbers in public and private facilities and the age of equipment. It is not clear at present how useful this document will be for planning purposes. As there are currently no mechanisms in place for regulating the distribution of health equipment in the private sec- tor it can do little more than highlight the inequalities in distribution. It is also unlikely that ratios will be reintroduced in the NHS as they lack sensitivity to other local characteristics such as the availability of equipment in the private sector. (See Mechanisms for controlling health care technologies under the section Pharmaceuticals and health care technology assessment for more in- formation.)
Human resource planning All staff within the NHS are civil servants and all new posts have to be approved by the Ministry of Finance.
A numerus clausus was introduced in 1977 which limits the number of places available in medical schools. This was in response to the excess of
22
Portugal
European Observatory on Health Care Systems
doctors created after the revolution in 1974, when many doctors from the colonies returned to Portugal in order to complete their training.
The distribution of medical personnel is not controlled or regulated by the state. However the high levels of investment in regional facilities outside Lisbon and Porto in recent years means that they are more attractive to doctors wishing to work in a well-equipped environment.
Regulation
The Portuguese system is highly normative, with extensive regulation. There are numerous and sometimes very restrictive controls over pharmaceutical goods, high-technology equipment and the education, training and registration of health personnel. The defined rules and procedures, however, are not always adhered to or enforced.
The main responsibility for regulation and national quality standards lies at the central level with the General Directorate of Health. Presently there is a Sub-Director of Quality who is responsible for standards within health care provision. A plan to establish a separate institute for quality was announced at the beginning of 1999. This body will have the same status as other institutes within the Ministry of Health and will produce guidelines for the accreditation of medical facilities.
The National Institute of Pharmaceuticals and Medicine (INFARMED) was established in 1993. This body is responsible for the regulation of pharmaceu- ticals and medical equipment. It is supported by the Pharmaceutical Inspection Service, Pharmacovigilance Service and The Official Laboratory for Pharma- ceutical Quality Control. A full description of their respective functions is given under Regulation and Control of Pharmaceuticals.
Management
Primary care health centres (described under Primary health care) are directly under the managerial control of the RHAs.
Public hospital services are currently managed by a four-member council or hospital board, consisting of a director, usually a doctor, and a general administrator (both appointed by the Minister of Health), a head doctor and a head nurse (both elected by peers).
There is, however, an experiment to allow public hospitals to be put under the control of private sector management. The legal reform which enabled this practice was part of the 1990 Law on the Fundamental Principles of Health (16). This stated that management of NHS institutions and services could be
23
Portugal
Health Care Systems in Transition
handed over to the private sector through management contracts. These con- tracts could be applied to the whole health institution, i.e. hospital or health centre, a particular service or any functionally autonomous part of them. Health institutions and services managed in this way would be included in the NHS, thus obliging the management authorities to guarantee access to health care in the same way as other NHS services.
This experimental type of management is currently operating at the Fernando Fonseca Hospital in Amadora, part of Lisbon. By granting hospitals public enterprise status, it releases them from the constraints of public employment regulations.
In order to facilitate the movement of personnel from the public hospitals to the privately-managed hospitals, the state guarantees a position for all personnel if they return to the NHS within three years. This is causing huge retention problems for the privately-managed hospitals as many doctors leave their jobs just before the three-year deadline is reached. Evaluation of these hospital reforms was expected in April 1999.
Decentralization of the health care system
The five regional health administrations were established by law in 1993 under the NHS Statute (16). Previously the hospitals had been the direct responsibility of the General Directorate of Hospitals and the health centres fell under the direct hierarchical authority of the General Directorate of Primary Health Care. These two directorates were merged to form the new General Directorate of Health in the Ministry of Health. The separation of primary care from secondary and tertiary care within the hierarchy of the Ministry was reflected in the way in which services were organized locally. This reorganization was part of a broader strategy to try and integrate and coordinate further levels of provision.
Previously the NHS was organized regionally through 18 regional health administrations (RHAs). However these had no responsibility for health centres and acted simply as the disbursers of funds for hospitals. The rationalization of the RHAs into five regions has been accompanied by devolution of financial responsibility. RHAs are given a budget from which they have to provide health care services for a defined population allowing them greater autonomy over the way in which the budget is spent.
24
Portugal
European Observatory on Health Care Systems
25
Portugal
Health Care Systems in Transition
Health care finance and expenditure
The Portuguese health care system is a mix of public and private financing. The NHS, which provides universal coverage, is predominantly funded through general taxation. The health subsystems, which provide
comprehensive coverage to about a quarter of the population, are funded mainly through employee/employer contributions (including state contributions as an employer). A large proportion of funding is private, mainly in the form of direct payments by the patient and to a lesser extent in the form of premia to private insurance schemes and mutual institutions, which cover respectively 10% and 7% of the population.
Table 5 shows the percentage of total health expenditure (THE) financed through different agents. Taxation accounts for the largest amount, with 61.6% of the THE financed in this way in 1997. This includes expenditure on direct provision within the NHS and in the form of subsidies to the health subsystems which operate for public sector employees. The proportion attributed directly to social insurance schemes is only 4.8% (1996). Out-of-pocket payments accounted for 44.6% of THE in 1995. This is one of the highest in Europe (see the section on Out-of-pocket payments).
Table 5. Main sources of finance by funding agents (as % of total expenditure on health care) 1985–1997
Source of finance 1985 1990 1991 1992 1993 1994 1995 1996 1997
Public Taxes 51.2 54.8 55.8 55.9 55.6 68.2 62.6 63.0 61.6 Health subsystems 3.4 3.7 4.2 4.5 4.3 5.2 4.8 4.8 –
Private Out-of-pocket 45.4 46.3 43.1 44.0 45.3 46.6 44.6 – – Voluntary insurance 0.2 0.8 0.9 1.2 1.3 1.4 1.4 1.5 1.7
Source: OECD health data, 1998 (32).
Main systems of finance and coverage
26
Portugal
European Observatory on Health Care Systems
Public financing
Taxation The NHS is mainly financed directly by taxes. A soft budget for total NHS expenditures is established within the annual national budget. Actual health expenditures usually exceed the budget limits by wide margins, requiring the approval of a supplementary budget. Apart from direct transfers from govern- ment, the NHS has its own receipts that are mostly generated and spent by hospitals. These include payments received from patients for special services such as individual rooms, payments from beneficiaries of health subsystems and private insurers, payment received for the hiring of premises and equip- ment, income from investment, donations, fines, admission charges and co- payments (for drugs, consultations and diagnostic tests). In total this accounts for about 7% of total NHS revenues and is estimated to account for as much as 20% of the overall hospital budget.
Health subsystems The health subsystems, which pre-date the establishment of the NHS, are normally financed through employer/employee contributions, with a large contribution paid by the state as employer. Contributions by employees are obligatory for most funds.
Most beneficiaries of public sector health subsystems contribute 1% of their salary. In private subsystems the contribution can vary, sometimes beneficiaries pay nothing at all. The employee’s contribution is really symbolic with the larger part paid by the employer.
Generally the benefits received exceed those provided within the NHS. The employer-employee contributions are often insufficient to cover the full costs of care and consequently a significant proportion of costs are shifted onto the NHS. Most enrolees of these funds do not declare their membership when receiving treatment within the NHS, thus exempting the funds from responsi- bility for the full costs of care for their members.
Private financing
The main sources of private financing in Portugal consist of out-of-pocket payments both to the public and private sector and risk rated premia to voluntary health insurance schemes. There are also a small number of individuals who make private contributions to mutual funds.
27
Portugal
Health Care Systems in Transition
Voluntary health insurance Approximately 10% of the population have taken out some form of voluntary health insurance (VHI). Mostly this is group insurance provided by the employer: less than 10% of people with health insurance have individual policies. Policies tend to be selective in nature and lack comprehensiveness. The majority of VHI policies in Portugal are valid for only one year and consequently companies have the power to cancel the contract and/or refuse to renew the contract. As age is strongly associated with increased health care costs, many companies will try to exclude anyone over the ages of 65 or 70 years old.
A tax reform in 1988 made most health expenditures, including co-payments and payments to private doctors, fully deductible from taxable personal income. Tax deduction for health insurance premiums was covered by a general ceiling on insurance premiums up until 1999 when a stand-alone limit was introduced. This policy meant there was little incentive to purchase or use private insurance. The value of this implicit government subsidy has been estimated at 4.8% of direct tax revenues or between 0.2% and 0.3% GDP. Incentives are skewed in favour of out-of-pocket expenditure.
Corporate insurance policies are more generous as the corporate tax laws are more liberal. Even so, few firms currently provide private group health insurance. It seems likely however that if there is to be any further growth in the market it will be in the area of group and employer insurance policies.
The main reasons for a potential growth in the private insurance market can be summarized as follows:
• the tax incentives which encourage high earners and companies to take out private health insurance;
• the social status which VHI confers on enrolees as it is indicative of a certain level of income;
• the difficulty in accessing the NHS and dissatisfaction with the services provided.
Mutual funds About 7% of the population are covered by mutual funds, which are funded through voluntary contributions. They are non-profit organizations that provide limited cover for consultations, drugs and more rarely some inpatient care. They do not exclusively provide health benefits to associates so it is difficult to calculate the health component of the contributions.
28
Portugal
European Observatory on Health Care Systems
Out-of-pocket payments In recent years, there has been increasing use made of co-payments in health care with the aim of making consumers more cost aware.
Out-of-pocket payments have consistently accounted for about 45% of total health expenditure in Portugal over the last ten years (see Table 5). The majority of this expenditure is on drugs, over 50% in 1994/1995 (see Table 6). The share of out-of-pocket expenditure on drugs has increased significantly from 46.2% in 1989/90 to over 55% in 1994/1995. Medical, nursing and paramedical services and therapeutic products make up the bulk of the rest. These three items of expenditure represent over 90% of a household’s out-of-pocket pay- ments on health care.
The co-payments on pharmaceuticals vary from 40% to 100% depending on the therapeutic value of the drug. Pensioners pay a reduced co-payment and the chronically ill are exempt from co-payments on some courses of medication. More detail about the level of co-payment for pharmaceuticals is given in the section on Pharmaceutical co-payments.
Table 6. Out-of-pocket spending on health, by type of expenditure (% of total out-of-pocket health expenditure), 1989/1990 and 1994/1995
1989/1990 1994/1995
Drugs 46.2 55.1
Medical, nursing and paramedical services 36.2 36.8
Therapeutic products 10.2 4.4
Hospital expenses 6.3 2.6
Private health Insurance* 0.6 0.6
Other 0.4 0.4
Source: National Institute for Statistics 1996 (29). * This is the percentage of a household’s expenditure which is spent on the purchase of private health insurance policies. This contrasts with Table 5 which shows the proportion of total health expenditure that is financed by voluntary health insurance companies.
Within the European Union, Portugal has one of the highest levels of out- of-pocket payments for health care (see Table 7)7.
Flat rate payments exist for consultations (primary care Esc.300 , hospital outpatients Esc.600 central and Esc.400 district hospital), emergency visits (health centre Esc.400 and hospital Esc.1000), home visits (Esc.600) and diagnostic tests and therapeutic procedures (variable). (Note: all figures for 1998). Transportation costs are paid by the patient, except in special circumstances,
7 Other available estimates of the out-of-pocket payments suggest that the OECD values may be overestimates and therefore the figures should be treated with some caution.
29
Portugal
Health Care Systems in Transition
such as when the patient has to travel a long distance, when costs are subsidized. Patients are exempt from co-payments and user charges if they are classed as “low income” (i.e. in receipt of supplementary benefit or unemployed), have special medical needs (i.e. the physically handicapped or those with chronic illnesses) and special patient groups such as pregnant women, children up to 12 years of age, drug addicts in rehabilitation and chronic mental patients.
External funding Since 1994 there has been a programme of investment in health care services, co-financed by the European Union. Through the European Regional Development Fund (ERDF) significant investments have been made. For each co-financed project the Portuguese contribution must be at least 25% of total investment. The external funding complements the Ministry of Health’s own capital expenditure plans.
Health care benefits
Theoretically, there are no services explicitly excluded from NHS coverage. However, throughout Portugal, there are some types of care which should be provided by the NHS but which are not available in practice (for example, adult dental care)8. In these cases activity is mostly in the private sector and reimbursed by the NHS. Apart from these instances, the NHS, at least in theory, is totally comprehensive.
Table 7. Out-of-pocket health expenditure in Portugal and selected European Union countries (% of total health expenditure and per capita US $PPPs) 1985–1995
1985 1990 1995 % Per capita % Per capita % Per capita
US $PPPs US $PPPs US $PPPs
Portugal 45.4 173 46.3 284 44.6 457 Austria 19.6 160 22.4 270 23.7 389 Finland 19.5 166 17.3 223 23.6 323 Denmark 11.3 120 12.5 171 13.3 228 Ireland 14.4 85 15.1 115 13.2 159 Germany 11.2 110 11.1 142 10.8 230 Luxembourg 9.2 82 5.5 82 6.2 129 United Kingdom 3.3 22 3.4 33 2.7 33
Source: OECD health data, 1998 (32). Note: Out-of-pocket expenditure includes cost sharing and direct payments to providers.
8 According to the Health Interview Survey 1995/1996 (8), about 92% of dental consultations were in the private sector.
30
Portugal
European Observatory on Health Care Systems
Regarding direct provision, the NHS predominantly provides hospital care, GP and mother and child care. Specialist and dental consultations, and diagnostic services are more commonly provided in the private sector and reimbursed by the NHS. There are also gaps in provision due to geographical inequities. Some areas, for example, are unable to provide certain specialist services to the population.
Pharmaceuticals
A national drug formulary of active substances and ingredients lists all drugs approved for use in Portuguese NHS hospitals. Any drugs which are prescribed to inpatients, yet do not appear in the formulary, must be approved by a committee of pharmacists and doctors in each hospital. About 30% of drugs prescribed in hospitals are outside the formulary. In the ambulatory sector and outpatient departments, doctors are free to prescribe any drug.
Waiting lists
Waiting lists are often viewed as a means of rationing care in the public sector as people may be encouraged to opt for the private sector. The results of a recent study in Portugal suggest that waiting lists are a growing problem. The number of patients on waiting lists amounted to almost 15% of total hospital discharges in a single year (33). There is currently a census taking place of patients on waiting lists. Early results suggest there are more people than expected on waiting lists. However this may be due to duplication, with some patients appearing on two or more waiting lists for the same procedure at different hospitals.
It is not possible to identify any areas of health care where explicit choices have been made about rationing. There have been discussions about defining a “basic package” of health care benefits, but until now there has been no indication of such a policy being implemented. Though rationing may not happen explicitly, it may occur implicitly within the NHS as a result of diffi- culties in access, the absence of specialists and doctors in rural areas and the lack of supply of certain services.
Health care expenditure
Total health care expenditure in Portugal measured as a share of GDP was 8.2% in 1996. The proportion rose steadily from as little as 3% in 1970 to its present level (see Fig. 3). Portugal spends marginally less than the western European average of 8.4% (1996); however, there has been a convergence
31
Portugal
Health Care Systems in Transition
Table 8. Trends in health care expenditure in Portugal, 1970–1997
Total expenditure on health care 1970 1975 1980 1985 1990 1995 1996 1997
per capita in current prices (escudos) 642 2 663 8 507 25 335 63 643 125 050 132 864 140 916
per capita in constant prices (1990) (escudos) 17 035 – 42 834 43 628 63 643 – 86 275 –
Value in current prices per capita (US $PPP) 43 145 260 381 614 1 025 1 071 1 125
Share of GDP (%) 2.8 5.6 5.8 6.3 6.5 8.2 8.3 8.2
Public as % of total expenditure on health care 59.0 58.9 64.3 54.6 65.5 60.5 59.8 60.0
Source: OECD health data 1998 (32).
Fig. 3. Trends in health care expenditure as a share of GDP (%), in Portugal and selected western European countries. 1970–1996
Source: WHO Regional Office for Europe health for all database (51).
2
3
4
5
6
7
8
9
1965 1970 1975 1980 1985 1990 1995 2000
P er
ce nt
ag e
of G
D P
( %
)
Portugal Italy Spain EU average
32
Portugal
European Observatory on Health Care Systems
Fig. 4. Total expenditure on health as a % of GDP in the WHO European Region, 1997 or latest year
Source: WHO Regional Office for Europe health for all database (51).
% of GDP
Tajikistan Republic of Moldova
Belarus Turkmenistan
Georgia Armenia Ukraine
Kyrgyzstan Uzbekistan
NIS average Kazakhstan
Russian Federation Azerbaijan
Croatia The former Yugoslav Republic of Macedonia
Slovenia Slovakia
Czech Republic Hungary Estonia Poland
CCEE average Lithuania Bulgaria
Latvia Bosnia and Herzegovina
Albania Romania
Germany Switzerland
France Sweden
Netherlands EU average
Israel Portugal Iceland Austria
Denmark Italy
Belgium Spain
Norway Finland
Luxembourg Greece Ireland
United Kingdom Turkey
1.2
2.2
2.7
3.0
3.0
3.2
3.5
4.2
4.5
5.0
5.1
6.4
8.0
2.6
2.8
3.5
4.5
4.7
5.1
5.3
5.3
6.0
6.5
7.0
7.1
7.7
8.8
9.0
3.8
6.7
7.0
7.1
7.1
7.3
7.4
7.4
7.6
7.6
7.7
7.9
8.0
8.2
8.4
8.5
8.5
8.6
9.9
10.2
10.4
0 2 4 6 8 10 12
123456789012345678 123456789012345678
33
Portugal
Health Care Systems in Transition
over time. Portugal now spends more than both Italy and Spain despite having spent considerably less than both these countries in 1970. Compared to the other southern European countries, it appears that Portugal has not contained health care expenditure growth as successfully. Table 8 also shows that the amount spent on health care has risen both in absolute terms and in relative terms over the last three decades.
Fig. 4 shows that Portugal’s GDP spend on health care is near to the western European average of 8.4%. It is one of the highest in western Europe with only Germany, France, Switzerland and the Netherlands spending a larger percentage of GDP on health care. Methodological difficulties with calculating both health care spending and the size of GDP mean that direct comparisons should be made cautiously.
Using instead US $ purchasing power parity (PPP) per capita as a measure of health care expenditure, one can see in Fig. 5 that Portugal falls well below the European Union average. Portugal spent US $PPP1125 per capita on health care in 1997 which is similar to other EU countries such as Spain (US $PPP1168) and Ireland (US $PPP1324). Within the EU only Greece spends less per capita (US $PPP974).
In Portugal the proportion of total health expenditure which is from public sources, i.e. money raised through taxation or health subsystems (that are frequently publicly funded), is 60% (see Fig. 6) the lowest in the European Region. Other southern European countries have slightly larger proportions of public expenditure, such as Spain with 78.7%, Italy 69.9% and Greece 74.8%. Portugal contrasts with the northern European tax-based systems such as Sweden (83.3%), the United Kingdom (84.5%) and Norway (82.2%).
Public health expenditure as a percentage of total health expenditure in Portugal has fluctuated over the last 20 years between 55% and 65% of total (see Table 8).
Table 9 shows general trends in the expenditure on different categories of health service provision in recent years. Inpatient care accounted for 36% of total expenditure in 1995, whereas ambulatory care was only 24%. Inpatient care as a percentage of total health expenditure has been rising. Pharmaceuticals consume a growing proportion of health expenditure up from 20% in 1980 to over 26% in 1996.
34
Portugal
European Observatory on Health Care Systems
Fig. 5. Health care expenditure in US $PPP per capita in the WHO European Region, 1997 or latest available year
Source: WHO Regional Office for Europe health for all database (51).
10
16
47
232
371
602
743
904
974
1125
1168
1324
1347
1447
1589
1728
1743
1747
1793
1814
1825
1848
2005
2103
2339
2340
2547
0 500 1000 1500 2000 2500 3000
Ukraine
Turkmenistan
Russian Federation
Turkey
Poland
Hungary
Slovenia
Czech Republic
Greece
Portugal
Spain
Ireland
United Kingdom
Finland
Italy
Sweden
EU average
Belgium
Austria
Norway
Netherlands
Denmark
Iceland
France
Germany
Luxembourg
Switzerland
U S $P P P s
1234567890123 1234567890123 1234567890123
35
Portugal
Health Care Systems in Transition
Source: WHO Regional Office for Europe health for all database (51).
Fig. 6. Public (government) health expenditure as % of total health expenditure in the WHO European Region, 1997 or latest available year
60
65
69
70
70
71
72
72
74
75
75
77
77
78
79
82
83
84
85
85
87
88
88
90
92
92
92
93
94
97
97
98
100
100
100
100
100
100
0 20 40 60 80 100
Albania
Bosnia and Herzegovina
Bulgaria
Croatia
Romania
Slovakia
The former Yugoslav Republic of Macedonia
Kazakhstan
Kyrgyzstan
Belarus
Poland
Czech Republic
Ukraine
Luxembourg
Lithuania
Slovenia
Belgium
Estonia
Latvia
United Kingdom
Iceland
Sweden
Norway
Spain
France
Germany
Finland
Ireland
Greece
Israel
Austria
Netherlands
Turkey
Italy
Switzerland
Hungary
Denmark
Portugal
Percentage
1234567890123 1234567890123
36
Portugal
European Observatory on Health Care Systems
As in many other health systems, despite attempts to prioritize primary health care over specialist hospital-based medicine, expenditure on ambulatory care services remains lower than on inpatient care. In the Portuguese health system, the reliance on hospitals may be due in part to the difficulties that health centres have in providing ambulatory care to the population, resulting in large numbers of the population attending emergency departments or specialist outpatient clinics.
Table 9. Health care expenditure by categories in Portugal (as % of total expenditure on health care) 1980–1996
1980 1985 1990 1991 1992 1993 1994 1995 1996
Inpatient care (%) 28.7 26.4 32.3 33.0 35.0 36.5 36.8 36.2 –
Ambulatory care (%) public only 25.2 26.8 23.5 23.9 23.1 27.8 26.1 24.2 –
Pharmaceuticals (%) 19.9 25.4 24.9 24.3 24.7 25.6 25.2 25.2 26.3
Public investment (%) 5.1 2.2 1.7 1.8 2.3 2.5 3.3 1.9 2.5
Source: OECD health data 1998 (32).
37
Portugal
Health Care Systems in Transition
Health care delivery system
Primary health care
Primary health care in Portugal is delivered by a mix of private and public health service providers. In this section, primary health care will be taken to cover all health care provided out-of-hospital by both generalists and
specialists, and other non-specialist care and services such as dental care services, physiotherapy, radiology, and diagnostic services.
Public sector
Primary health care in the public sector is mostly delivered through publicly funded and managed health centres (HCs). Each of them covers an average of 28 000 people. They employ in total 30 000 people (including regional health administration personnel). Of these, 25% are doctors (mostly general practi- tioners) and 20% are nurses. There are on average 80 health professionals per centre, but some have as many as 200, others as few as only one medical doctor. Centres currently have no financial or managerial autonomy but are directly run by the regional health administrations (RHAs). The Ministry of Health allocates funds to the RHAs which in turn determine the budget of each centre based on historical and activity costs.
Most primary health care is delivered by GPs in the health centre setting. However, some health centres also provide a limited range of specialized care. This is a result of the integration of social welfare medical services into the National Health Service at the end of the 1970s. Specialists who had worked for the Department of Social Welfare were transferred and given contracts in the newly established NHS health centres. The specialists who work in HCs belong to the so-called ambulatory specialities such as mental health, psychiatry, dermatology, paediatrics, gynaecology and obstetrics and surgery. However, very few of these posts will be filled when present incumbents leave.
38
Portugal
European Observatory on Health Care Systems
The range of services provided by GPs in HCs is as follows:
• general medical care, for the adult population and the elderly
• prenatal care
• children’s care
• women’s health
• family planning and perinatal care
• first aid
• certification of incapacity to work
• home visits9
• preventive services, which include immunization and screening for breast, cervical and prostate cancers.
Patients must register with a GP. Theoretically, there is freedom of choice of GPs. People can choose among the available clinicians within a geographical area. Some people seek health care services in the area where they work but most choose a GP in their residential area.
GPs work with a system of patient lists, on average approximately 1500 patients. There are GPs with patient lists exceeding 2000 and others with fewer than 1000. People may change GP if they apply in writing, explaining their reasons, to the RHA board. There is no statutory limit to how often someone may change their GP.
According to international sources, the number of physician contacts per person in Portugal is 3.2 (1996/1997), one of the lowest in the EU with only Sweden having fewer contacts (2.9) (see Fig. 7).
National data used in Table 10 shows the number of medical appointments in health centres per capita has grown from 2.9 in 1980 to 3.3 in 1996. The number of home visits is insignificant.
Table 10. Medical appointments in health centres and home visits, 1980–1996
1980 1990 1991 1992 1993 1994 1995 1996
Medical appointments per capita 2.9 3.1 3.1 3.1 3.1 3.2 3.3 3.3
Home visits (1000) 1 031 191 162 141 141 130 125 122
Source: Department of Health Studies and Planning (38,40,42,44,46,48,50).
9 There are very few home visits made by GPs – less than 48 per year per health centre.
39
Portugal
Health Care Systems in Transition
Fig. 7. Physician contacts per person in OECD countries within Europe, 1996/1997 or latest available year
Source: OECD health data 1998 (32).
11
8.0
6.5
6.4
6.3
5.9
5.7
5.4
5.3
4.5
4.3
3.8
3.2
2.9
0 2 4 6 8 10 12
Switzerland (1992)
Belgium (1993)
France
Germany (1995)
Austria
United Kingdom
Average of countries shown
Netherlands
Denmark
Iceland
Finland
Norway (1991)
Portugal
Sweden
Number of contacts per person
123456789 123456789 123456789
40
Portugal
European Observatory on Health Care Systems
Facilities
The number of health centres and health posts has continued to grow throughout the 1980s and 1990s with a total of 2424 primary care medical units in 1996 (see Table 11).
Table 11. Number of primary care facilities in Portugal 1970–1996
1970 1980 1990 1996
Medical Units 1 935 2 195 2 249* 2 424 Health Centres - 265 354 382 Health Posts - 1 682 1 895 2 042
Source: National Institute for Statistics, 1990–1995 (23,24,25,26,27,28).
The facilities provided by each health centre (HC) vary widely across the country in terms of the physical structure and layout of the HCs:
• Some HCs were purpose-built and are therefore of a reasonable size, with a rational distribution of space, and discrete and segregated areas for different purposes;
• Some HCs, mainly those in large cities, were incorporated into residential buildings and consequently many are badly designed and are not patient- friendly;
• Some HCs, mainly those in rural areas which are operated by Misericórdias or belong to the church, were established in ancient hospitals and monas- teries (in the 1960s).
Due to the long waiting times for access to diagnostic facilities in the health centres, many patients prefer to go directly to emergency care services in hospitals or the private sector. In emergency departments the full range of diag- nostic tests can be obtained in a few hours. This leads to excessive demand at emergency departments and considerable misuse of resources as expensive emergency services are used for relatively minor complaints.
Challenges and reforms
The major problems currently facing primary health care are:
• Inequitable distribution of health care resources; Although there are a large number of health centres inland, there is a lack of health care personnel (mainly doctors and nurses) because the coastal areas are more attractive.
41
Portugal
Health Care Systems in Transition
• Difficult access to primary health care; Barriers to accessing health centres means that excessive numbers of people go directly to hospital emergency departments.
• Very limited public provision of services in continuing and home care;
• Weak reputation of the public primary health care system; For many people, the system lacks credibility and therefore encourages many patients to seek second opinions from private doctors or hospital out- patient departments;
• Lack of quality control programmes; There is no quality assurance process.
• Lack of coordination; There is very little coordination between primary health care centres, hospital doctors, hospitals and private doctors, leading to unnecessary repeat examin- ations and tests, which merely waste time and have no impact on health outcomes or quality of care.
• Lack of motivation of general practitioners; GPs in many places work in isolation and with poor incentives for produc- tivity due to their salaried status.
• The shortage of qualified ancillary staff in health centres.
Recent health care reform proposals aim to tackle these problems by: • increasing accessibility
• improving continuity of care
• increasing GP motivation, through changes in the payment system
• stimulating home care services
• identifying quality.
A number of pilot projects were established in 1995. Of particular interest is the Alfa Project which began in the Lisbon and Tagus Valley Region.
The objectives of these projects were:
• to increase GPs’ job satisfaction;
• to increase patients’ satisfaction with primary care services;
• to increase access to public health services – a greater availability of post- natal care, care centred on the citizen and more time for consultations;
• to improve quality;
• to rationalize prescriptions of pharmaceuticals and the number of diagnostic tests and examinations.
The Alfa Project experimented with a revised GP payment scheme in which groups of GPs were given overtime payments and other incentives in return for
42
Portugal
European Observatory on Health Care Systems
an assurance of providing 24-hour cover and adequate referral and follow-up of patients. A preliminary internal evaluation of these pilots indicated that the integrated models were successful, mainly because there was an improvement in satisfaction from both citizens and providers. Some of the principle ideas behind the reforms have been adopted nationally and new methods of remunera- tion for GPs are being introduced (see the section on Payment of health care professionals).
More radical reforms to grant greater autonomy to health centres have been proposed but not yet enacted. These would grant both financial and adminis- trative autonomy to the centres. There is currently no solidarity between GPs who often feel isolated within the health centre. The proposal aims to increase a sense of team spirit by establishing smaller groups of GPs within the centre. Each group of doctors would be contracted by the RHA and would be accountable to the RHA for the care they provide. In order to encourage doctors to join the scheme the RHA are considering offering incentives such as bonus- payments, improved quality of premises and a special credit scheme for equip- ment and investment in facilities (this is awaiting approval from the Ministry of Finance). One of the additional responsibilities which will form part of the contract is the provision of 24-hour cover.
Diagnostic and therapeutic services Portugal also has a large independent private sector which provides diagnostic and therapeutic services to NHS beneficiaries under contracts called “convenções”. These medical contracts cover ambulatory health facilities for laboratory tests and examinations such as diagnostic tests and radiography (they are scarce in medical consultations). The contracts operate as follows: the NHS publicly declares the terms of service and prices that the NHS is willing to pay. All providers who are prepared to meet the criteria and who meet basic quality standards can register. A list of all those providers who have registered is published annually. In principle, patients can choose from any of the providers who appear on the contracts. Many patients actually go directly to the emergency departments of hospitals where they can obtain all necessary tests within a much shorter time. Prices do not vary according to the level of service which means providers have little incentive to improve the quality of services.
Dental care The publicly-funded oral health care system in Portugal is not very compre- hensive. There are very few NHS dentists, so people normally use the private sector. Some dentists contract with one or more of the health subsystems. Each scheme defines its own list of eligible treatments and fees. The schemes are
43
Portugal
Health Care Systems in Transition
usually slow to pay and the fees are low. Those dentists not under contract may provide care to patients covered by the schemes; patients pay directly and are then reimbursed by the scheme. As well as dentists, dental hygienists (who have a more limited training) provide dental care though it must be under the direction of a dentist.
Referral process and links between primary and secondary care
The first point of contact within the public system is the GP in a health centre (HC). Theoretically, people have no direct access to secondary care and GPs are expected to act as gatekeepers, i.e. patients should have a prior consulta- tion with a GP before they can access specialist hospital or ambulatory services. Frequently, there is a delay in obtaining a consultation depending on the specialty.
In reality, most people go directly to the emergency department in hospitals if they have any acute symptoms. A very large number of the attendees at hospital emergency units do not however need immediate care. People who go to emergency departments and genuinely need specialized care are immediately referred. There are user charges for emergency visits (currently Esc. 400 for visits to health centres and Esc.1000 to hospital emergency departments). How- ever these do not appear to affect the inappropriate use of emergency services.
Those patients who are covered by the health subsystems can go directly to private hospitals and specialists allowed by their schemes. Private doctors can also refer them to NHS hospitals. Those patients covered by private health insurance may be eligible for private specialist consultations but this will de- pend on the benefit package offered.
Reforms The problem of lack of coordination between hospitals and health centres and the large numbers of patients by-passing the referral system has prompted reform. One of the reform proposals, which has been on the agenda since the foundation of the NHS, is the development of local health units. The idea was to link a hospital (or several hospitals) with a number of health centres based partly on geographical proximity and partly on the balance of specialities and availability of an accident and emergency department. These “health units”, whose main focus was health care institutions, were established but they failed to achieve any improvements in coordination and did not fulfil the aim of integrating, coordinating and facilitating continuity of care.
The latest reform, enacted in May 1999, goes further and proposes the establishment of “local health systems”. These would include private institu- tions and local councils as well as the medical services provided within the
44
Portugal
European Observatory on Health Care Systems
NHS. These local health systems are expected to lead to a more adequate and functional interlinking between secondary and primary, public and private care. They aim to change the present scenario of lack of coordination among services and embrace a broader sense of health care with the focus on the population. They are community-based and include all providers, both public and private, as well as representatives of citizens’ groups (either someone nominated by the municipal council or a consumers’ association where they exist). The pro- posal is to calculate population-based budgets based on total health expenditure in the area covered by the health system. These resources will then be allocated at a local level amongst all providers based on an assessment of health needs in the area. The RHAs are currently developing a methodology to assess health needs on which decisions about financing priorities and allocations will be based.
Public health services
The public health services in Portugal are responsible for surveillance of health status and identification of its determinants. Public health services are also responsible for health promotion and disease prevention at community level and for the evaluation of the impact of health promotion and disease prevention activities.
The organization of public health services nationally is the responsibility of the General Directorate of Health (GDH). The GDH is responsible for the establishment of programmes, definition of strategy and approval of national plans.
At a regional and local level the main actors are as follows:
• Local health authority – an extra level of administration in the public health system, which consists of a public health doctor usually in a health centre;
• Public health doctors and sanitary technical staff;
• Regional health authority – work in health sub-regions and support public health services through the provision of regional laboratories;
• GPs – responsible for health promotion as part of their day-to-day work including family planning, antenatal services and screening programmes.
Public health doctors have the primary responsibility for the promotion of health and surveillance of disease. However in many health centres these responsibilities are transferred to GPs. Their responsibilities include:
• Ensuring compliance of local services, e.g. restaurants, hotels, etc. with health and safety standards;
45
Portugal
Health Care Systems in Transition
• environmental inspections of places of work;
• building safety and housing inspection;
• communicable disease surveillance and notification.
Reform of public health services
There is a policy to strengthen public health at both regional and local levels through provision of epidemiological expertise and leadership functions in health promotion issues. Of particular note is the establishment of SARA (Rapid Response System), a new information and management system for health emer- gencies, whether related to food safety, communicable diseases or environ- mental health. This project aims to build a national information network for all public health staff, connecting all levels of public health care. It will provide th