The state of Portuguese hospitals at the beginning of the decade made significant gaps apparent: quality control was absent, and there was no standardised information system to facilitate the control of the performance of managers and healthcare establishments. These managers did not have any effective incentives, or the autonomy necessary, especially in the area of managing human resources, to improve the performance of the hospital. In addition, the hospitals suffered from important personnel problems: while the number of doctors per hospital bed was greater than the OECD average, the number of nurses was only half of the OECD average, which effected the efficiency and quality of care.
The Portuguese healthcare system is composed of three co-existing systems: the national health service (Serviço Nacional de Saùde, SNS), the special social programmes of health insurance for certain professions (subsystems of the state), and private, voluntary health insurance. The national health service offers universal coverage. Furthermore, approximately 25% of the population is covered by the healthcare subsystems, 10% by private health insurance and 7% by mutual funds.
The Ministry of Health is responsible for developing health policy as well as managing the SNS. Five regional health administrations are responsible for implementing the national health policy objectives, developing directives and protocols, and supervising healthcare services. Decentralisation efforts have aimed at shifting financial and management responsibility to the regional level. In practice, the autonomy of regional health administrations over budget setting has been limited to primary care.
The national health service is predominantly funded through general taxation. The contributions of employers (including the state) and of employees represent the principal source of finance of health subsystems. Furthermore, direct payments by patients and voluntary health insurance premiums represent a large part of the financing. Private healthcare spending amounts to approximately 30% of total spending,reflecting a large share of out-ofpocket payments (including co-payments) which, combined with a strong dependence on indirect taxes, results in a funding system which is slightly regressive.
The Ministry of Finance fixes the annual budget of the national health service based on historical spending and plans laid down by the Ministry of Health, who allocates a budget to each regional administration so that they can provide care to a geographically defined population. The public hospitals are financed by case-mix adjusted global budgets and fixed by the Ministry of Health. Since 1997, an increasing portion of the budget is based on Diagnostic Related Grouping as well as unadjusted outpatient activity. Primary healthcare facilities are financed by the regional health administrations and have no financial or administrative autonomy.
The primary health services in the public sector are principally carried out by general practitioners andfamily doctors who work in the primary healthcare centres. There is no direct access to secondary healthservices, with general practitioners acting as gatekeepers. Secondary and tertiary care are ensured by the hospitals, even if certain health centres offer specialist ambulatory care.
of the Portuguese Healthcare System
Current political agenda in Portuguese healthcare combine the expansion and re-orientation of the policies launched by preceding governments (hospitals considered as public enterprises, PPPs, the promotion of generic medicines) with a new approach in terms of the role of the public, as well as the private and social sectors. The Portuguese health system is now viewed as a network of healthcare services between different sectors. The citizens must choose beween different options according to their needs and their preferences. Certain reforms which affect secondary care and hospitals in particular (management of waiting lists, public- private partnerships, incorporated hospitals) are described in the following article, which tackles the Portuguese hospital sector.
The present government programme focuses equally on the reorganisation of medical emergency services, the development of longterm care, a pricing system for publicly financed healthcare delivery, financial incentives to encourage productivity in the public sector, informing the public about public hospital and health centre performance, and finally, fiscal incentives for the development of private health insurance.
Despite the enormous progress realised in the last few years in the matter of health policy, the health system will always and forever face a number of challenges. Compared to other European countries, thePortuguese health sector spending is characterised by an elevated level of resources compared to its GDP, a low level of spending per capita, significant spending on medicines, and very high spending compared to other countries possessing a similar national health system structure. It has also been shown that the systemis performing low in terms of equity, efficiency, accountability, and responsiveness objectives. Numerous health reforms have been legislated, but never completely implemented.
In the near future, it will be essential for Portugal to improve its access to health services, to reduce the inequalities and to guarantee better coordination between primary and secondary care levels. A tendency towards the diversification of healthcare organisms is in view in Portugal, as in most EU countries. Emerging new forms of public management and public-private partnerships aim at improving accountability and cost containment in the health sector.
In relation to ICT (Information and Communication Technology), the Ministry of Health, via the national health plan, defined the guiding principles by which health establishments can contribute to the realisation of advances in healthcare between 2004 and 2010. The priorities are: technical assistance, hospital access network, use of information technologies and communication, quality certification, the creation and upgrading of health centres, and the modernisation of hospital services.
e-Health is also a national priority in the National Action Plan for an Information Society. The main objective is to utilise ICT to place the citizen at the centre of the health system, while increasing the quality of services provided, increasing the efficiency of the system and reducing costs. The e-Health policy has three lines of action with the following objectives:
• Health information networks: Improve the backbone communication infrastructure of the health sector. Encourage use of this backbone to introduce addedvalue services and improve information exchange between health service providers.
• Online health services: Improve communication between doctors and patients. For example, use new applications based on Internet and mobile services to assist continuous monitoring of some chronic illnesses (diabetes, high blood pressure, obesity, drugdependency), support medication and treatment follow-up, and support the patient’s family.
• User cards for patients: Introduce patient cards to provide more efficient and effective personalised patient care.
Besides the national personal data protection law, the clinician practice guidelines, and the publicity and medicines marketing guidelines, there is no separate legal framework for e-Health or telemedicine practice.
Financing and investment are undoubtedly two critical themes for Portuguese healthcare. The limited and unbalanced human resource structure, reflecting poor long-term resource policy and planning capacities in the past, might represent one of the strongest challenges the Portuguese health sector may have to face in the years ahead.
A comprehensive health strategy is now in place in Portugal. This is expected to bring together health promotion and protection issues with health service concerns. (CH)