6.2 Future developments
The Government Programme (2015–2019) and the National Health Plan 2012–2020 are the main strategic documents for health policy. While the National Health Plan provides a generic guidance to monitor health gains, the Government Programme is the main reference for the practical implementation of policy measures.
Despite some developments in recent years (see section 6.1), several challenges remain in the Portuguese health system. One of the first challenges is how to increase healthy life expectancy at age 65. While Portugal is in a comfortable position regarding life expectancy at birth (see section 1.4), health problems at age 65 are hampering life expectancy in the country. The Government Programme foresees an integrated health promotion process that encompasses all public policies influencing population health. This programme is expected to involve several ministries and civil society partners.
An additional challenge is to achieve a balance between financial sustainability and the possibility of expansion for the NHS. In fact, the high health care spending and the unsatisfactory efficiency of the NHS were, for some time, hampering the possibility of improvement in underserved fields such as dental health, mental health or palliative care and general NHS quality. The majority of costs in the health system are related to caring for people with long-term chronic conditions. It has been argued that financial sustainability will only be achieved through reducing the incidence of these diseases, developing new models of health care provision for them and ensuring that evidence is systematically applied everywhere and waste (i.e. system inefficiencies) is reduced to a minimum (Crisp et al., 2014). The financial sustainability of the health system will depend on political willingness to introduce Health in All Policies, which has not been introduced yet, effective health promotion and concerted actions by citizens, the society and health care professionals. The next years will provide an answer to the question of whether recent changes in budgetary procedures implemented across the public sector in Portugal will be able to contain debt accumulation by NHS institutions (e.g. price reductions across the NHS, particularly in payments to private providers).
Another challenge relates to the wages of health care workers in the public sector. Although most of the wage cuts introduced in 2012 are currently being reversed, the payment to health care workers in the NHS, particularly physicians, is lower than in the private sector (not to mention other European countries). Recent years saw a wave of emigration among health care workers in Portugal, mainly nurses, and the challenge in the coming years for the NHS is to be able to maintain the motivation of its workforce, and to contain and reverse the drain of professionals (see section 4.2.3). Given that private health care providers receive higher salaries, both doctors and nurses have been moving to the private sector or even to other countries.
At an organizational level there are two main future challenges. The first one relates to the reorganization of the hospital network. The recent creation of hospital centres (with two or more hospitals) lacks an assessment from which to generate evidence that those reforms have produced the desired efficiency gains. Also, which intern model works better to improve hospital management, achieve permanent cost savings and promote efficiency in a highly pressured sector remains a question to be answered in the next years. Internal functioning of NHS hospitals needs to be redefined, as their autonomy has been reduced since 2008, with the employment of new staff being subject to the government’s approval through the Ministry of Finance. Although the previous government postponed any decision in this regard, political pressure at both national and local levels is forcing decisions on the construction of some new hospitals. The technical and scientific evidence to support political decisions about the construction of new hospitals, PPPs, hospital centres and local health units is still very weak.
The second major organizational challenge is the primary care network and its integration with other levels of care. The goal of including every NHS user in a GP patient list can only be achieved with serious investments in human resources and infrastructure, but is crucial to tackling the inequalities in accessing health care, which are still real in the Portuguese NHS. Additionally, referral to other levels of care (including the RNCCI) needs to be improved to promote efficiency in the system. Lastly, the role of public health units at local level needs to be clearly defined and the near future will tell whether, with the necessary investment, they will become active agents of health promotion and disease prevention.
In this regard, the Ministry of Health has tried to simplify the recruitment process of new GPs in order to shorten the gap between the tender and the effective placement. For example, in June 2016, a tender was launched, making 338 places available in several primary care units (Announcement No. 7530-B/2016, of 15 June 2016), and in November 2016, a new tender made 108 places available (Announcement No. 14426-A/2016, of 17 November 2016). As a result, by the end of 2016, the number of NHS users registered with a GP has decreased to 769 537 (from 1 053 844 in December 2015), and the proportion of NHS users covered by a GP reached 92.1% (ACSS, 2017).
Skill mix in the NHS, meaning a more efficient combination of health professions, is a discussion that was only recently initiated in Portugal. Nowadays, the training and qualifications of nurses and allied health professions encompass wide-ranging and substantial knowledge, but their role in the health system has not changed and the health system is still centred on physicians. The promotion of the recently created role of Family Nurse is still awaiting further government measures.
Finally, civil society participation in the design and evaluation of health policies and the empowerment of citizens are important challenges for the Portuguese health system. The creation, in 2016, of the National Health Council, which includes representatives of patients, health workers, municipalities, universities and many other entities, can represent an important step in this regard. In May 2016, the Ministry of Health published a law facilitating the referral of NHS users from primary care settings to outpatient consultations in NHS hospitals out of their referral area. This has increased the freedom of choice within the NHS and constitutes an important step towards patient empowerment.
A new hospital management regime was approved (Decree-Law 18/2017, of 10 February 2017) with the goal of improving the system’s efficiency and the professionalization of teams.
At the organizational level, the law establishes the rules and principles of integrated accountability centres (centros de responsabilidade integrada), which aim to improve accountability of health care, patients’ access and the quality of services provided, and to increase the productivity of allocated resources.
At the management level, the new regime aims to strengthen the management board’s capacity as well as the intermediate management structures, whose members should have specific and relevant training in health and adequate professional experience. The management board will include a member proposed by the Ministry of Finance. In Local Health Units, the management board will also include a member appointed by local authorities. The procedures for the nomination of the head of the departments will be publicly advertised, thus allowing individual applications, for the sake of transparency and equal opportunities.
More information (in Portuguese): https://dre.pt/application/file/a/106431320