2.3. Organization

The Portuguese health system is characterized by three coexisting and overlapping systems: the NHS; special public and private insurance schemes for certain professions or companies (health subsystems); and private VHI. Fig2.1 outlines the relationships between the various bodies, organizations and institutions that comprise the health system.

Fig2.1

The overall legal framework of the system is the 1990 Basic Law on Health (Law No. 48/90, of 24 August 1990), which introduced the principles for the organization and functioning of the health system (Barros, Machado & Simões, 2011). The 1990 Basic Law on Health is a pivotal legal act for the Portuguese health system that established: the regionalization of health service administration, by creating the RHAs; the possibility of privatizing sectors of health care provision, by allowing the state to promote the development of the private sector and the private management of public health care facilities; the possibility of privatizing sectors of health care financing, by promoting the option for VHI and the possibility of creating an alternative health insurance (opting out); the integration of health care, with the possibility of creating health care units that would assemble hospitals and primary care units within a single region.

The health care delivery system in Portugal consists of a network of public and private health care providers; each of them is connected to the Ministry of Health and to the patients in its own way. The key relationships are shown in Fig2.1, with the Ministry of Health coordinating all health care provision and the financing of public health care delivery.

2.3.1. Ministry of Health

The central government, through the Ministry of Health, is responsible for developing health policy, and overseeing and evaluating its implementation. Fig2.2 outlines the organization of the Ministry of Health. Its core function is the regulation, planning and management of the NHS. It is also responsible for the regulation, auditing and inspection of private health care providers, whether they are part of the NHS or not.

Fig2.2

The policy-making process takes place within government. It is frequent that government rulings go to institutional partners for consultation. Usually, there is no detailed evaluation plan or ex post assessment of policy measures. The implementation of the policies is a task of the RHAs. The Ministry of Health performs some assessment and audit, as well as the Court of Auditors and the Inspectorate-General of Health-related Activities, but the policy evaluation process is not systematic.

Many of the planning, regulation and management functions are in the hands of the Minister of Health. The two state secretaries have responsibility for the first level of coordination, under delegation by the Minister of Health.

The Ministry of Health comprises several institutions: some of them under direct government administration; some integrated under indirect government administration; some having public enterprise status; a Health Regulatory Agency (HRA) formally independent from the Ministry of Health in its actions and decisions; and a recently created consultative body: the National Health Council (created by Decree-Law No. 9/2016, of 23 August 2016).

The following central services are under the government’s direct administration, which implies that they are hierarchically run by the Ministry of Health.

• The Secretariat-General for Health (Secretaria-Geral da Saúde), which provides technical and administrative support to the other sections of the Ministry, coordinates their work, and provides assistance to staff within various government offices. It also gives support to other institutions, services and bodies not integrated within the NHS, concerning internal resources, legal advice, information and public relations.

• The Inspectorate-General of Health-related Activities (Inspecção-Geral das Actividades em Saúde), which performs the audit, supervision, and disciplinary function in the health sector, both in NHS institutions and services, and in private institutions.

• The Directorate-General of Health (Direcção-Geral da Saúde, DGH), which plans, 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. It is also responsible for public health programmes, quality and epidemiological surveillance, health statistics and studies.

• The Directorate-General for Intervention on Addictive Behaviours and Dependencies (Serviço de Intervenção nos Comportamentos Aditivos e nas Dependências), which promotes the reduction of both legal and illegal drugs consumption, the prevention and treatment of addictive behaviours, and the decrease of dependence.

The following central services are under the government’s indirect administration, including public institutes or other bodies.

• Central Administration of the Health System (Administração Central do Sistema de Saúde, ACSS), which is in charge of managing financial and human resources, facilities and equipment, systems and information technology (IT) of the NHS. It is also responsible for the implementation of health policies, regulation and planning, along with the RHAs, namely in health service contracting.

• The National Authority on Drugs and Health Products (Autoridade Nacional do Medicamento e Produtos de Saúde, INFARMED), which regulates and supervises the pharmaceuticals and health products sector, following the highest standards of public health protection (see section 5.6). It aims to ensure that all health care professionals and patients have access to safe, efficient and quality pharmaceuticals and other health products.

• The National Institute for Medical Emergencies (Instituto Nacional de Emergência Médica, INEM), which delineates, participates in and assesses the activities and performance of the Integrated System of Medical Emergency, guaranteeing immediate assistance to injured or severely ill patients (see section 5.5).

• The Portuguese Institute for Blood and Transplantation (Instituto Português do Sangue e da Transplantação), which guarantees quality and safety regarding donation, analysis, processing, storing and distribution of human blood and blood components, as well as human organs, tissues and cells. Additionally, the Institute for Blood and Transplantation regulates, at a national level, the pharmaceuticals related to transfusions and guarantees that there is a stock of secure blood and blood components available when needed.

• Institute for Protection and Assistance in Illness (Instituto de Proteção e Assistência na Doença, ADSE), which guarantees the effective access to social protection regarding health care services to public administration workers and their families (see section 2.3.6). This is the health subsystem for civil servants and it is under the indirect administration of both the Ministry of Health and the Ministry of Finance.

• National Institute of Health, Dr Ricardo Jorge (Instituto Nacional de Saúde Doutor Ricardo Jorge, INSA), which is the reference laboratory of the Portuguese health system, incorporating the functions of national observatory and national reference laboratory in the Portuguese health sector. It is responsible for conducting, coordinating and promoting health research at the Ministry of Health. It also has the objective of producing evidence for policy and action in public health. Currently, the National Institute of Health is organized in six departments: Food and Nutrition; Infectious Diseases; Epidemiology; Genetics; Health Promotion and Chronic Diseases; and Environmental Health. All operative units composing the departments develop multidisciplinary programmes in problem areas of public health, namely: performing research and development (R&D), health monitoring, training, laboratory external quality assessment and general health services.

• Regional Health Administrations (Administrações Regionais de Saúde, RHAs), which are responsible for implementing national health policy regionally, and coordinating all levels of health care. The NHS, although centrally financed by the Ministry of Health, has had a regional structure since 1993 comprising five health administrations: North, Centre, Lisbon and the Tagus Valley, Alentejo, and Algarve. A health administration board, accountable to the Minister of Health, manages the NHS in each region. The management responsibilities of these boards are a mix of strategic management of population health, supervision and control of hospitals, and centralized direct management responsibilities for NHS primary care.

The RHAs work in accordance with the principles and directives issued in regional plans and by the Ministry of Health. Their main responsibilities are the development of strategic guidelines; coordination of all aspects related to health care provision; supervision of hospitals and primary care management; establishment of agreements and protocols with private bodies; and liaison with government bodies, religious charities (Misericórdias), other private non-profit-making bodies, and municipal councils. They are also in charge of developing a long-term care network.

• Hospitals belonging to the Public Administrative Sector (Hospitais do Sector Público Administrativo), which currently are a minority of public hospitals that were not converted into Public Enterprises (Entidades Públicas Empresariais, EPE). In other words, these are public institutions without an enterprise status and continue to be managed by civil service rules.

The following services are part of the public enterprise sector, including public hospitals and other entities.

• Shared Services – Ministry of Health (Serviços Partilhados do Ministério da Saúde, SPMS), which provides specific shared health-related services in matters of purchasing and logistics, financial management, human resources, information and communications systems, and other supplementary and subsidiary activities to organizations that are part of the NHS, irrespective of their legal nature, as well as to bodies and services of the Ministry of Health and any other organizations, as long as they carry out activities specific to the health field.

• Local health units (Unidades Locais de Saúde), which were created in 1999 to generate greater and better communication between primary care and hospitals through a vertical integration of different levels of care. Currently, there are eight local health units in Portugal: Matosinhos, Northern Minho/Viana do Castelo and Northeast/Bragança (North); Guarda and Castelo Branco (Centre); and Northern/Portalegre, Southern/Beja and Coastal/Santiago do Cacém Alentejo (Alentejo).

• Hospital Centres and other Public Enterprise Hospitals (Centros Hospitalares e Hospitais), which include hospitals that are ruled as EPEs. Among them, there are hospitals that were grouped into Hospital Centres and others that remained as individual institutions. The rationale behind the creation of Hospital Centres was to improve efficiency through better coordination between institutions providing hospital care in the same geographical area. Both Hospital Centres and Hospitals are public enterprises, meaning that hospital boards have some level of autonomy and management accountability, compared with hospitals from the public administrative sector.

There are other bodies related to health care that do not belong to the Ministry’s administration, either directly or indirectly.

• National Health Council (Conselho Nacional de Saúde), which is the consultative and independent body for the Ministry of Health. It is responsible for issuing recommendations and advice on measures to enforce the implementation of health policies.

• Health Regulatory Agency (Entidade Reguladora da Saúde), which is an independent body responsible for the regulation of the health care sector. Its functions include the supervision of health care institutions regarding operating requirements, patients’ access to health care and patients’ rights defence, quality of health care provision, economic regulation, and promotion of competition in the health care sector (see section 2.8).

2.3.2. Ministry of Finance

2.3.3. Ministry of Labour, Solidarity and Social Security

This Ministry is responsible for social benefits such as pensions, unemployment benefits and disability benefits. In 2000 social security expenditure in Portugal corresponded to 9.6% of GDP, but in 2013 this percentage had risen to 26.9% (DGSS, 2015). The Ministry’s collaboration with the Ministry of Health has improved in recent years. Joint projects include a review of certification for sick leave, a programme to improve coordination between health care and social services, and an initiative to improve continuity of long-term care for the elderly and people with disabilities. For more information on the relations between the two ministries in the long-term care network, see section 3.6.

2.3.4. Ministry of Science, Technology and Higher Education

This Ministry is responsible for undergraduate medical, nursing and allied health professionals’ education and for academic degrees. However, specialized postgraduate medical training is the joint responsibility of the Portuguese Medical Association (Ordem dos Médicos) and the Ministry of Health. Specialized training in other health professions is, in general, within the scope of the Ministry of Health and, in some cases, of professional associations (e.g. nurses).

2.3.5. Local government

There are a number of initiatives being undertaken in cooperation with the municipalities, such as promoting greater traffic and pedestrian safety, and encouraging physical exercise. Nutrition is also being promoted in close cooperation with the media, schools, sports organizations and local authorities. However, overall, the role of municipalities in the Portuguese health system is rather marginal. The involvement of the municipalities in health promotion programmes is limited to a few specific projects, namely child oral health, environmental health and healthy behaviours.

2.3.6. Health subsystems

Almost four decades after the inception of the NHS in Portugal, the historical remnants of the pre-existing social welfare system still persist in the form of health insurance schemes for which membership is based on professional or occupational category. These are often referred to as health subsystems (subsistemas de saúde). In addition to the health insurance coverage provided by the NHS, approximately 25% of the population is covered by a health subsystem or VHI. More precisely, approximately 16% of the population are covered by a health subsystem (ERS, 2016c), and in 2015 more than 2.7 million individuals (around 25.8% of the population) were covered by individual or group private health insurance (ASF, 2016). Health care is provided either directly or by contract with private or public providers (and in some cases by a combination of both). Access is generally limited to members of a specific profession and their families.

In 2005, a number of subsystems operating in the public sector were integrated into the main subsystem, the ADSE (Assistência à Doença dos Servidores do Estado), for civil servants. Therefore, the benefits are now standardized across the health subsystems. Before 2005 the separate subsystems included:

• SSMJ (Serviços Sociais do Ministério da Justiça), for employees of the Ministry of Justice;
• ADMA (Assistência na Doença aos Militares da Armada), for the Navy;
• ADME (Assistência na Doença aos Militares do Exército), for the Army;
• ADFA (Assistência na Doença aos Militares da Força Aérea), for the Air Force;
• SAD-PSP (Serviço de Assistência na Doença da Polícia de Segurança Pública), for police officers; and
• SAD-GNR (Serviço de Assistência na Doença à GNR), for Officers of the National Republican Guard.

In the private sector, the major health subsystems are: the health subsystem for the employees of the historic telecommunications operator Portugal Telecom (Portugal Telecom Associação de Cuidados de Saúde, PT-ACS), for postal service employees at Correios de Portugal, and for banking and associated insurance employees (Serviços de Assistência Médico-Social), set up by their respective unions on a regional basis. There are also a few additional smaller funds. Some of the funds are associated with and run by trade unions and managed by boards of elected members.

Until 2013, the Ministry of Finance controlled the largest health subsystem, ADSE, which was mandatory for all civil servants until 2009. Since 2009, civil servants may easily opt out from ADSE. In 2015, ADSE was transferred to the Ministry of Health (Decree-Law No. 152/2015, of 7 August 2015). However, in 2017, ADSE was converted into a public institute with special regimen and participated management (Decree-Law No. 7/2017, of 9 January 2017), and it was renamed Institute for Protection and Assistance in Illness (Instituto de Protecção e Assistência na Doença). ADSE is now under the indirect administration of both the Ministry of Health and the Ministry of Finance. Created in 1963, this subsystem covers more than 10% of the population, with 1.25 million enrolled beneficiaries in 2015 (ERS 2016c) (see section 3.6.1 for more information on health subsystems).

Private health care providers mainly fulfil a supplementary role to the NHS rather than providing a global alternative to it. Currently, the private sector mainly provides diagnostic, therapeutic and dental services, as well as some ambulatory consultations, rehabilitation and hospitalization.

2.3.7. Religious charities – Misericórdias

Misericórdias are independent non-profit-making institutions with a charitable background. The Lisbon Misericórdia is an exception, because it is a public enterprise with a board that is appointed by the Ministry of Labour, Solidarity and Social Security rather than elected by members. Despite their historical role as one of the main providers of health care services, currently these institutions operate very few hospitals: a total of 15 hospitals distributed across the country, but mostly concentrated in the North region (10). Most of the institutions are now focused on long-term care provision, being the largest provider in the National Network for Long-term Care (Rede Nacional de Cuidados Continuados Integrados, RNCCI), both in the number of units and capacity.

2.3.8. Private health insurance companies

On the financing side, the main private actors are the private health insurance companies. VHI was introduced in 1978 (see section 3.5). Initially, only group policies were offered, but individual policies have also been available since 1982. The number of people insured has grown from approximately 500 000 in 1990 to almost 2.7 million in 2015 (ASF, 2016). There is a mechanism of double coverage in place, hence increasing mostly the number of specialized medical appointments. People can even benefit from triple (or more) coverage, that is, from the NHS, a health subsystem from their job, VHI and having coverage from another health subsystem as an extension of their spouse’s coverage. It is not uncommon for beneficiaries of health subsystems to also sign up to VHI.

2.3.9. Professional associations and unions

Founded in 1938, the Portuguese Medical Association (Ordem dos Médicos) is the professional organization for physicians. There are also two main unions: the National Medical Federation (Federação Nacional dos Médicos, FNAM) and the Independent Medical Union (Sindicato Independente dos Médicos, SIM). Membership of the Medical Association is mandatory for practising physicians. Its functions include:

• accreditation and granting of licences to practise;
• accreditation and certification of postgraduate medical training; and
• application of the disciplinary code, with powers to warn and punish doctors.

As for the unions, their main role is to advocate for physicians’ rights as employees, mostly concerning wages and employment issues.

Equivalent bodies also exist for pharmacists (Ordem dos Farmacêuticos, founded in 1972), dentists (Ordem dos Médicos Dentistas, founded in 1991), nurses (Ordem dos Enfermeiros, founded in 1998), psychologists (Ordem dos Psicólogos, founded in 2008) and nutritionists (Ordem dos Nutricionistas, founded in 2010).

The National Association of Pharmacies (Associação nacional de farmácias), a union for pharmacies, covers almost 95% of pharmacies, though membership is optional. It has an important corporate role and operates as a fund, handling the majority of pharmaceutical payments between the NHS and the associated pharmacies. Its mission includes modernizing facilities and organizational models; continuous education and training of pharmacists; dissemination of information on up-to-date practices in pharmaceuticals management and dispensing; implementation of a global computerized information system for the pharmacies; and collaboration with the government in projects and campaigns in the public health domain.

2.3.10. Patient groups

Organizations specifically advocating for patients are active disease-based advocacy groups, such as those devoted to diabetes, cancer, haemophilia, hepatitis and HIV/AIDS. These groups are specifically focused on patients and families affected by a particular condition, and promote the allocation of resources for patients’ treatment and care in those particular disease groups, as well as donations and awareness campaigns.

More recently, the project “More participation, better health” (Mais participação, melhor saúde) was created with the aim of promoting the participation and capacity building of representatives of people with and without illness in policy and institutional decision-making in Portugal (GAT, 2016).