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01 April 2024 | Country Update
Health Emergency and Transformation Plan for the NHS -
05 March 2020 | Policy Analysis
The Portuguese Government approves a Plan to improve NHS responsiveness -
08 February 2018 | Policy Analysis
Unhealthy foods banned from NHS institutions
6.1. Analysis of recent reforms
Recent reforms in the health sector in Portugal are inevitably linked to the MoU (MoU, 2011) signed between the Portuguese Government and the three international institutions (the European Commission, the European Central Bank and the IMF), in exchange for a €78 billion loan (see section 1.2). The document, which was evaluated every three months and successively revised during these evaluations, included a list of mandatory measures (in order to unblock payments from the IMF, the European Central Bank and the European Commission) linked to the health sector, which were implemented by the Ministry of Health in recent years.
The reforms implemented by the Ministry of Health since 2011 can be summarized in five dimensions:
- regulation and governance
- health promotion
- pharmaceutical market
- long-term and palliative care
- primary and hospital care.
Table6.1 shows the key policy areas undergoing reforms from 2010 onwards and their related goals. Although most measures enacted since 2011 were determined by the MoU, in some areas, such as primary and hospital care, reforms launched before 2011 continue to be pursued to develop the Primary Healthcare reform (ongoing since 2005, and reprioritized in 2016; see section 6.1.5) and to facilitate the reorganization of the hospitals in hospital centres.
Table6.1
In late May 2024, the Portuguese Government approved the Health Emergency and Transformation Plan to implement urgent and priority measures that guarantee access to health care tailored to the needs of the population. The Plan foresees, in exceptional cases, and when the response capacity of the NHS is exhausted, the provision of services by the social and private sectors. The Plan provides 54 measures structured into five strategic axes according to three levels of priority. The timely response axis targets waiting lists, especially for oncological surgery. The babies and mothers’ safety axis includes measures for timely and safe referral of all pregnant women. The emergent and urgent care axis targets emergency departments in the NHS, both structurally and organizationally, and derives part of the services to clinics (to be created) and primary care. The axis on family health aims to increase GP coverage, particularly in deprived areas. The mental health axis aims to increase the number of psychologists at primary care and the promotion of anxiety and depression targeted programs.
More information (in Portuguese): https://www.sns.gov.pt/plano-de-emergencia-e-transformacao-na-saude
Context
The Portuguese NHS has faced several budgeting problems in recent years. In fact, the budgeted funding for the NHS is not enough to cover its real spending, resulting in long waiting lists for appointments or surgeries, as well as an increasing struggle for hospitals in hiring human resources.
To tackle this problem, the government has elaborated a plan to improve the responsiveness of the NHS, focused on three main goals: achieve better access, improve health care workers’ motivation and increase investment in the NHS network.
Improving the NHS responsiveness means to promote a better and faster response from the NHS to the citizens, together with better salaries for health care workers.
Impetus of the reform
The Portuguese Government has given a special focus and relevance to the need of increasing investment in the NHS, without abandoning the quality and levels of public spending and budgetary sustainability of the health sector. The consolidated total expenditure in the Health Budget for 2020 is €11.3 billion, while the initial NHS budget is €941 million higher than in 2019.
Additionally, the NHS debt to suppliers is constantly increasing, reaching €2 billion in November 2019. The predicted NHS deficit for 2019 is €447.2 million, with total spending being €10.6 billion.
To achieve these goals, the government proposes robust management, to increase the value of program contracts, to correct persistent budget imbalances, to modernize and qualify facilities and equipment and to strengthen recruitment and motivation of health professionals, all materialized in the Plan to Improve NHS Responsiveness (Plano de Melhoria da Resposta do SNS) (1,2).
Content of the reform
The Plan to Improve NHS Responsiveness is based on a framework for multi-annual investments, which integrates and expands investments: NHS investments include the construction of hospitals and improvements of facilities and equipment. The main objective is to achieve a progressive and sustained reduction in the level of under budgeting in the NHS, allowing the reduction of deadlines to suppliers.
The phased elimination of under budgeting in health is accompanied by a reduction in the NHS global debt, by reducing the deadline of payments. Between 2015 and 2019, overall annual spending increased by 18% (€1.6 million), mainly due to increasing spending with health care workers (+26%) and medicines and medical devices. As a result, the Plan reinforces the Health Budget in €800 million for 2020 and reinforces the 2019 budget with an additional €550 million to pay the NHS debt. It also approves the framework for multi-annual investment program in a total of €190 million. During the next four years, new hospitals will be built, with a total estimated impact of €950 million, €102 million of those in 2020.
The Plan recognizes the need for a framework to recruit health workers and for incentives to increase performance of the NHS units and address health needs. As so, it establishes a framework for recruitment of 8 400 new health workers between 2020 and 2021 and it reinforces the autonomy for recruiting health workers of all NHS public enterprises.
In terms of the management of the NHS, the Plan defines €100 million to operationalize performance payment schemes in Integrated Responsibility Centres in NHS hospitals. This means there is a reinforcement of intermediate management in NHS hospitals, with internal contracts and incentives for results both to professionals and to institutions. The estimated financial impact is €100 million. Hospital administrations will have tighter accountability rules so that patients’ access and overall efficiency increase.
Nevertheless, management premiums in NHS public enterprises hospitals are dependent, inter alia, on the absence of late payments and the approval of management contracts and activity plans and budgets. Management premiums are financial incentives similar to those in place in primary care (salary bonuses) when certain targets are met: number of appointments, number of surgeries, decreasing of waiting lists, etc.
References
(1) Portugal. Resolução do Conselho de Ministros nº 77/2019, de 2 de Maio. Available at https://dre.pt/home/-/dre/122202591/details/maximized, (accessed 14 january 2020)
(2) Portugal. Resolução do Conselho de Ministros Nº 198/2019, de 27 de Dezembro. Available at https://dre.pt/application/file/a/127582822, accessed 14 january 2020)
Context
In December 2017, a reform aiming to forbid unhealthy foods in bars at NHS institutions has been passed by the Government. This measure is in line with the 2015–2019 Health Programme of the Portuguese Government, which establishes health promotion as a priority and emphasizes the adoption of measures to promote healthy eating as a key element of that policy (Portuguese Government, 2015). Further, the 2012–2020 National Health Plan also foresees “Healthy Policies” as one of its strategic axes, highlighting that everyone should contribute to the creation of enabling environments that promote health and the well-being of the population (National Health Service, 2012).
Since 2016, the government has taken several actions to promote health, including the creation of the 2016 National Programme of Health Education, Literacy and Self-Care (Diário da República, 2016), the renovation of the Priority Health Programme on Healthy Eating Promotion for four new years (2016–2020) and the creation of the 2016 Priority Programme on Physical Activity. These measures are also aimed to promote informed health decisions by citizens.
Additionally, in early 2016, the Ministry of Health signed a commitment with representatives of the food industry to reduce the volume of sugar packages (from 8 g to 5 g) in commercial establishments (for example, restaurants, bars, and cafés). In June 2016, the Ministry of Health also took measures concerning the installation and operation of vending machines in NHS institutions. On one hand, selling products with excess of salt or sugar in those vending machines was prohibited, and on the other hand, a range of healthier foods that should be made available was defined. This removal of unhealthy food from vending machines did not cause an overall decrease in sales. Finally, by the end of 2016, the government approved the taxation of sugared drinks, aiming to significantly reduce its consumption, especially among young people and adolescents.
Rationale for the reform
The reform forbidding sweets in bars at NHS institutions is part of a wider strategy to promote healthy eating habits, especially in health institutions, which have an increased responsibility in this area.
The limitation of some unhealthy products in bars and cafeterias of NHS institutions aims to obtain a significant and sustainable reduction of the excessive consumption of sugar and salt, as well as to avoid the transfer of their consumption from vending machines to catering areas. Overall, the government expects to promote the availability of healthy food in bars and cafés in hospitals and health centres, as part of a healthy food pattern.
Content of the reform
The Dispatch No. 11391/2017, of 28 December 2017 (Diário da República, 2017), determines that bars, cafeterias and buffets, located in institutions of the Ministry of Health, whether under direct or indirect administration of the Ministry of Health or belonging to the NHS (for example, hospitals, primary healthcare units, and local health units), cannot sell or advertise the following products: salted, including patties, croquettes, pies and related products; pastry, namely cakes or pastries with puff pastry and/or with cream and/or covering; bread with a sweet filling, milk bread or croissant with sweet filling; meats, in particular sandwiches or other containing chorizo, sausage, ham or bacon; sandwiches or other products containing ketchup, mayonnaise or mustard; cookies and biscuits exceeding 20 g of fat (per 100 g) and/or 20 g of sugar (per 100 g); soft drinks; sweets, in particular candies, caramels, sugared chewing gum, lollipops or jelly sweets; sugared or salted snacks; sweet desserts; cereal bars; fast food, including hamburgers, hot dogs, pizzas or lasagna; chocolates in packages exceeding 50 g and chocolates with filling; alcoholic beverages; and sauces namely ketchup, mayonnaise or mustard.
Instead, the same Dispatch defines as mandatory the provision of free drinking water, and preferably the following foods: semi-skimmed/skimmed milk; low fat yoghurt, preferably sugar-free; fresh or ripened cheese and curd cheese; fruit juices and/or vegetable juices, beverages containing at least 50% fruit and/or vegetables; bread, preferably mixed with whole wheat flour and containing less than 1 g of salt per 100 g of bread; fresh seasonal fruit; salads; vegetable soup; oleaginous fruits, unsalted and sugar-free; sugar-free herbal teas and infusions. At the time of writing, the impact of this measure has not been assessed and no information is available on the perception from both patients and the food industry on this measure.
References
Diário da República (2016). 2016 National Programme for Health Education, Literacy and self-Care (in Portuguese) (https://www.dgs.pt/em-destaque/programa-nacional-de-educacao-para-a-saude-literacia-e-autocuidados.aspx, accessed 8 February 2018
Diário da República (2017). Dispatch No. 11391/2017, of 28 December 2017 (https://dre.pt/application/file/a/114414905, accessed 8 February 2018)
National Health Service (2012). 2012–2020 National Health Plan (in Portuguese) (http://pns.dgs.pt, accessed 8 February 2018)
Portuguese Government (2015). 2015–2019 Programme of the XXI Constitutional Government (in Portuguese)
6.1.1. Regulation and governance
The publication of the framework law for all regulatory bodies (Law No. 67/2013, of 28 August 2013) led to a strengthening of the powers of the HRA, created in 2003. The new status of the HRA, published in August 2014 (Decree-Law 126/2014, of 22 August 2014), gives the HRA exclusive jurisdiction for assessing and monitoring all complaints by users of all health care services. Additionally, the HRA also supervises the process of licensing all health care providers, including issuing, maintaining and revoking licences, as well as inspecting facilities. The HRA’s new status has strengthened regulation in areas directly contributing to safeguarding patients’ rights and to the quality and safety of health care provision.
The ACSS also saw its powers being reinforced by assuming an increasing role in the health system (see section 3.3.3 and subsection Payment of hospitals in section 3.7.1). Some previous bodies within the Ministry of Health have been integrated in the ACSS, which currently leads the process of human and financial resources planning and allocation within the NHS, contracting with all NHS providers, linking the Ministry of Health with other bodies and entities, developing and implementing IT within public health care providers, as well as managing the RNCCI.
6.1.2. Health promotion
The National Health Plan (2012–2016) was recently extended until 2020 and provides the main strategies for public health action to be implemented in the next years. As main goals, the Plan sets the decrease of premature (before age 70 years) mortality by 20%, the increase of healthy life expectancy at age 65 by 30%, and the reduction of risk factors for noncommunicable diseases such as smoking and child obesity (with no quantitative objective attached).
The new extended Plan (2012–2020) defines four main strategic axes to guide health policies in Portugal in the next years: health citizenship, equity and appropriate access to health care, quality and policies to improve lifestyles (see section 5.1).
The DGH is responsible for the Plan’s design and implementation (see sections 2.5 and 5.1). The Plan seeks the involvement of the public, private and social sectors in order to achieve the goals and obtain health gains in the Portuguese population, assuring equity, quality and financial sustainability of the health system.
Another recent change regarding health promotion was the termination in 2012 of the four national vertical programmes on HIV/AIDS, oncological diseases, cardiovascular diseases and mental health, which were replaced with priority health programmes. Those resulted from the reorganization of the four existing national vertical programmes as mentioned above and existing initiatives on respiratory diseases, tobacco control, healthy nutrition, control of antimicrobial resistance and diabetes. The goal was to prioritize the main causes of mortality and morbidity in Portugal, as well as the important risk factors that are prevalent among the population, such as overweight, smoking and sedentary lifestyle (see section 1.4). Each priority health programme is organized in accordance with the national health strategies, as included in the National Health Plan, and has a four-year term. In 2016, the length of programmes was extended (2016–2020) and two more programmes were added: viral hepatitis and physical activity (Dispatch No. 6401/2016, of 16 May 2016). The new Programme for Physical Activity aims to promote healthy lifestyles and tackle sedentary lifestyle, whereas the new Programme for Viral Hepatitis aspires to develop hepatitis prevention and control strategies, scale up best practices for hepatitis C management, particularly among patients in prison, and promote hepatitis monitoring and surveillance (see section 5.1).
6.1.3. Pharmaceutical market
Among the reforms implemented in Portugal since 2011, the pharmaceutical sector has seen significant changes following shifts towards the generic market and strengthening of procurement processes. Main reforms, which were linked to the MoU, include changes to the structure of distribution margins, the promotion of generic drugs, the use of clinical guidelines by physicians, and the redefinition of the international referencing rules that establish prices of new pharmaceutical products.
As a result, public pharmaceutical expenditure in ambulatory care decreased by approximately 12% between 2011 and 2014. Overall, there was a price reduction of drugs that counterbalanced the increasing consumption in that period, with the decrease on the overall pharmaceutical expenditure achieved by price reductions rather than reduced access to drugs or reduced reimbursement from the NHS (Barros, 2015).
6.1.4. Long-term and palliative care
The RNCCI (Rede Nacional de Cuidados Continuados Integrados) was created in 2006 together with a task force that coordinated it (see section 5.8). It filled the gap of the increasing need for long-term care in the public sector. The network provides three types of care through convalescence (recovery) units, medium-term care and rehabilitation units, and long-term care units, with different goals according to each type of unit. The resources available and the payment systems are also different among these units.
The RNCCI has significantly expanded since its inception. Mostly, the expansion of the network occurred through contracts with private facilities, which increased the supply of long-term care beds (see section 5.8). Recent changes introduced to the RNCCI include the integration of the coordination of the public network of long-term care beds in the ACSS from December 2012. Additionally, the National Network of Palliative Care was created in 2012 under the responsibility of the Ministry of Health. This network complements and expands existing structures, such as those that already existed in the RNCCI. The network is coordinated by a National Commission for Palliative Care in close touch with regional and local structures, and aims to provide palliative care to patients, irrespective of their age and pathology, who are suffering due to advanced disease (Law No. 52/2012, of 5 September 2012).
6.1.5. Primary and hospital care
Other major reforms have been undertaken in the hospital and primary health care settings. In acute care, Portugal has pursued a number of reforms to rationalize its hospital sector through the specialization and concentration of hospital services. New management models and payment systems have been introduced, with the transformation of public hospitals into public enterprises (Hospitais EPE) (see section 2.3.1). To tackle the increased operational costs of NHS hospitals, additional measures were taken, including the reduction of overtime payment, restrictions to hiring new personnel, and restrictions to external service contracting. Ambulatory surgery has been strongly promoted in recent years, namely through incentives to hospitals, the creation of infrastructures, benchmarking monitoring and price revision. The main goal was to promote better resource allocation and increased efficiency among NHS hospitals. The model of PPPs was applied in some hospitals, but no more PPPs are being planned for the health sector (see subsection Investment funding in section 4.1.1).
Further, some measures have been recently approved to improve patient choice across NHS hospitals. Since May 2016, NHS users can be referred to a hospital outside their residence area, as long as waiting times for a given procedure or outpatient consultation are shorter than in their residential area (Decision No. 6170-A/2016, of 9 May 2016). The brand new NHS website (https://www.sns.gov.pt) was launched in February 2016 and provides information on waiting times regarding outpatient consultations for several specialties. The NHS users are now able to analyse together with their GP the best option in order to receive timely treatment in an NHS hospital. The GP, in agreement with the patient’s best interest, will refer the patient for the first time to any of the NHS hospitals where there is the specialty concerned by using criteria of geographical proximity and average response times for the relevant consultation.
In primary care, the reform enacted in 2007 was pursued, although at a slower pace. Therefore, the goal of expanding FHUs and including all NHS users in a GP patient list was not achieved. In 2008, primary health care units were reorganized under groups of health care centres (ACES), with the aim of increasing efficiency and enforcing health policies and strategies at the local and regional levels. Given the emergency services overuse by the population, a number of measures were taken to promote patients’ use of primary health care and alleviate emergency rooms at NHS hospitals, including hiring new GPs, expanding FHUs and facilitating access to primary health care (by expanding the number of NHS users registered with a GP).
In February 2016, the Ministry of Health launched the “Strategic Plan for Primary Healthcare Reform” to reprioritize the 2005 Primary Healthcare Reform and expand the number of NHS users enrolled in a GP patient list. For this purpose, the Ministry of Health has facilitated retired physicians to return to the NHS.
The Plan also comprises a number of measures regarding primary health care contracting in terms of selected indicators. The Plan is intended to create a global reference framework of indicators for primary health care in a range of areas. There are no major changes to the 2005 Primary Healthcare Reform, which aims to improve the quality of primary health care provision mainly through expanding FHUs and interlinking to hospital care. Recently, the Ministry of Health has established a maximum number of FHUs to transit from a remuneration model without financial incentives (model A) to one with financial incentives (model B) during 2016 (Dispatch No. 6739-A/2016, of 20 May 2016).