Located in the south-west of Europe, with a mainland area of 91,900 km², along with the archipelagos of Açores and Madeira, Portugal is a developed country with a lot to offer, including a health system with many strengths. Amid the economic crisis and an ageing population, however, the country is facing problems in this sector. In response to this, the Ministry of Health has proposed a sustainability plan for hospitals to overcome the crisis, which anticipates improved efficiency, disease prevention and safety, among other benefits.
The total population in Portugal has seen a five percent increase over the last decade. While in the 1970s only 38.8% of the population lived in urban areas, this rose to 58.2% by 2006. Most of the population is concentrated in two large metropolitan areas: Greater Lisbon (with approximately two million inhabitants) and Greater Oporto (with approximately 1.2 million inhabitants). The number of births has been declining steadily since the 1970s and the average age has been gradually rising. In terms of production and income, total gross domestic product (GDP) in 2010 was 272.4 billion US dollars, according to current purchasing power parity (PPP).
In terms of health status, beyond the crude death rate in 2009 (Table 1), life expectancy at birth was 79.5 years (76.5 years for males, 82.6 years for females), which places the country just above the average, according to the Organisation for Economic Cooperation and Development (OECD). Over the past five decades, both sexes have seen similar improvements, with women currently living on average six years longer. In the past four decades, Portugal has also had one of the largest reductions in infant mortality rates among OECD member countries.
The Organisation of the Healthcare System
The Portuguese healthcare system is a national health system (NHS) that was founded in 1979. It was formed mostly based on structures already in place (hospitals and primary care centres), but these were not necessarily organised as an integrated set of providers.
In the last few years, reforms have seen both primary care centres and hospitals grouped both horizontally and vertically, forming local health units, in order to improve management, efficiency and quality.
As is typical in Beveridge influenced systems, the Portuguese NHS and therefore its hospitals have been financed mostly with funds from general taxation. Healthcare costs have grown consistently above both the inflation rate and the increase in GDP.
Primary care and secondary care are supposed to work together in articulation. However, as is often the case, transition of both patients and information between the two levels is not as smooth as desired, raising issues in terms of coordination and continuity of care. More recently, a third level, long-term care, has been added to the equation. Long-term care is expected to reduce the need for longer hospital stays, but the number of available beds is still insufficient.
Total health spending accounted for 10.1% of GDP In 2008, according to the latest figures from the OECD Better Life Index. This placed Portugal, in 2009, above the OECD average of 9.5%. Portugal has also typically received a slightly higher percentage of private financing than other OECD countries. This amounted to 2,508 US dollars per capita after adjusting for PPP.
Comparing total health expenditure per capita with other countries’ GDP per capita, there seems to be a positive correlation between the two. Portugal is well within this trend.
Portugal currently has 3.8 physicians per 1,000 population. This data refers to all physicians who are licensed to practice and thus includes doctors not actually practicing, however. In any case, this result places Portugal above the OECD average. This has been the result of a steady increase over the last five decades. In 2009, Portugal had 5.6 nurses per 1,000 population, which places it below the OECD average, in spite of considerable growth in the past decade, including significant improvements in the country’s ability to train these professionals. We are thus slightly above the OECD average in the first case (albeit with a ratio of graduates to physicians below ideal), and the opposite is true when looking at nurses.
In terms of healthcare management, Portugal has had a postgraduate course in hospital management for over 40 years now. Taught by the National School of Public Health (http://www.ensp.unl.pt/), it was for a number of years a requirement to enter hospital management; recent changes to the legislation made this optional rather than compulsory. Simultaneously, other schools started teaching health services management, mostly at the postgraduate level.
The Portuguese Hospital System
Most hospitals and hospital beds in Portugal are public. Numbers of both, however, have been decreasing in recent years. The number of hospitals has decreased mostly through mergers, with several hospitals forming hospital centres, under a common executive board. The number of beds has decreased mostly as part of an international trend, associated with more effective and efficient treatments and the move of a number of activities (namely surgical) to ambulatory care. In 2009, there were 2.8 acute care hospital beds per 1,000 population.
A look at the number of acute care beds suggests these were less affected than other healthcare beds. The occupancy rate of curative (acute) care beds has for the past decade been stable around 72 %, with several experts arguing for the need to reduce the number of beds as a way to increase this rate. The average length of stay in 2009 was recorded to be 5.9 days. This too has dropped significantly over past decades.
As is common elsewhere in the developed, western world, Portugal faces problems brought by an ageing population, with increased incidence and prevalence of chronic conditions and multi-morbidity. The Ministry of Health is thus currently insisting on health promotion and disease prevention as a means to ensure the overall sustainability of the system.
Eight areas of clinical and health promotion have been identified as priorities: diabetes, HIV infection and AIDS, tobacco consumption, healthy eating, mental health, oncology, respiratory diseases, and cardio and cerebrovascular diseases.
The current government is keen on promoting actions on lifestyle changes, with a special focus on diet and exercise, while reducing the consumption of tobacco, alcohol and illicit drugs. Some of these require intersectoral policies. Target populations include the young and the elderly, with healthy and active ageing as an objective. In organisational terms, governance relies both on the national level, for policy and budgeting, and also on five regional health administrations.
Patient access to the system is still a problem in some areas, with the prevalence of long waiting lists and waiting times, particularly for elective surgery, outpatient visits and diagnostic tests. The past few years, however, have seen the development of a number of specific programmes in an attempt to overcome this situation.
In recent years Portugal has also shown particular interest in the quality of healthcare provided. There is a national strategy for quality in healthcare, which was approved in 2009, and the country has participated in global safety programmes led by the World Health Organisation (WHO), among other schemes. The Ministry of Health is also currently in the process of transposing to the Portuguese legislation the directive on crossborder care. As a part of this process, the ministry is working on the definition of referral centres to integrate with European reference networks.
All actions taken by the government follow a national health plan, stretching from 2012 to 2016. The previous plan (2004- 2010) was very positively reviewed by the WHO (http://www.euro.who.int/__data/assets/ pdf_file/0003/83991/E93701.pdf). Internally, comprehensive reviews are being undertaken in primary care, emergency services and long-term care, based on the advice of national experts.
The main current issues with the Portuguese national health system are related to the current economic crisis in the country (and Europe in general), and the need to ensure the system’s sustainability. In the context of the global economic crisis, the country and the healthcare system are currently under pressure to be more efficient while ensuring access and quality. The healthcare sector is thus undergoing some reform, with specific efforts directed at hospitals. These focus around eight axes:
1. Implementing a More Coherent Hospital Network
Specific measures include the redefinition of the network of hospitals, given the recent formation of several hospital centres, which group hospitals, and the existence of a number of referral networks (specialty-based) that need coherence and updating.
2.Defining a More Sustainable Financing Policy
Specific measures include the development of costing systems and the improvement of benchmarking efforts between hospitals.
3. Integrating Care to Improve Access
Specific measures include the improvement of referral criteria between primary care centres, hospitals and long-term care departments.
4.Making Hospitals More Efficient
Specific measures include the implementation and monitoring of clinical guidelines, and raising ambulatory surgery rates.
5. Ensuring Quality as a Major Trait of Hospital Reform
Specific measures include a reduction of current rates of hospital acquired infections and rates of cesarean sections.
6. Investing in Information Systems as a Sustainability Factor
Specific measures include the implementation of the electronic health record and guaranteeing the validity of all information in the system.
7. Improving Governance
Specific measures include celebrating management contracts with the boards and assessing board performance.
8. Strengthening the Role of Citizens
Specific measures include making hospital benchmarking public and raising patient awareness of healthcare costs.
The Ministry of Health believes this strategy to be the only way to make the Portuguese healthcare system sustainable in the face of one of the biggest economic crises seen in recent years, while at the same time improving its effectiveness, efficiency, safety, fairness, timeliness and patient centered charactersitics.