portugal hit (2011) _ health system review
TRANSCRIPT
PortugalHealth system review
Vol. 13 No. 4 2011Health Systems in Transition
Pedro Pita BarrosSara Ribeirinho MachadoJorge de Almeida Simões
Sara Allin (Editor) and Elias Mossialos (Editor in chief) wereresponsible for this HiT
Editorial Board
Editor in chiefElias Mossialos, London School of Economics and Political Science, United Kingdom
Series editorsReinhard Busse, Berlin University of Technology, GermanyJosep Figueras, European Observatory on Health Systems and PoliciesMartin McKee, London School of Hygiene & Tropical Medicine, United KingdomRichard Saltman, Emory University, United States
Editorial teamSara Allin, University of Toronto, CanadaMatthew Gaskins, Berlin University of Technology, GermanyCristina Hernández-Quevedo, European Observatory on Health Systems and PoliciesAnna Maresso, European Observatory on Health Systems and PoliciesDavid McDaid, European Observatory on Health Systems and PoliciesSherry Merkur, European Observatory on Health Systems and PoliciesPhilipa Mladovsky, European Observatory on Health Systems and PoliciesBernd Rechel, European Observatory on Health Systems and PoliciesErica Richardson, European Observatory on Health Systems and PoliciesSarah Thomson, European Observatory on Health Systems and PoliciesEwout van Ginneken, Berlin University of Technology, Germany
International advisory boardTit Albreht, Institute of Public Health, SloveniaCarlos Alvarez-Dardet Díaz, University of Alicante, SpainRifat Atun, Global Fund, SwitzerlandJohan Calltorp, Nordic School of Public Health, SwedenArmin Fidler, The World BankColleen Flood, University of Toronto, CanadaPéter Gaál, Semmelweis University, HungaryUnto Häkkinen, Centre for Health Economics at Stakes, FinlandWilliam Hsiao, Harvard University, United StatesAlan Krasnik, University of Copenhagen, DenmarkJoseph Kutzin, World Health Organization Regional Office for EuropeSoonman Kwon, Seoul National University, Republic of KoreaJohn Lavis, McMaster University, CanadaVivien Lin, La Trobe University, AustraliaGreg Marchildon, University of Regina, CanadaAlan Maynard, University of York, United KingdomNata Menabde, World Health Organization Regional Office for EuropeEllen Nolte, Rand Corporation, United KingdomCharles Normand, University of Dublin, IrelandRobin Osborn, The Commonwealth Fund, United StatesDominique Polton, National Health Insurance Fund for Salaried Staff (CNAMTS), FranceSophia Schlette, Health Policy Monitor, GermanyIgor Sheiman, Higher School of Economics, Russian FederationPeter C. Smith, Imperial College, United KingdomWynand P.M.M. van de Ven, Erasmus University, The NetherlandsWitold Zatonski, Marie Sklodowska-Curie Memorial Cancer Centre, Poland
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Health System Review2011
Portugal:
The European Observatory on Health Systems and Policies is a partnership between the WHO Regional Office for Europe, the Governments of Belgium, Finland, Ireland, the Netherlands, Norway, Slovenia, Spain, Sweden and the Veneto Region of Italy, the European Commission, the European Investment Bank, the World Bank, UNCAM (French National Union of Health Insurance Funds), the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.
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© World Health Organization 2011, on behalf of the European Observatory on Health Systems and Policies
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ISSN 1817-6127 Vol. 13 No. 4
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Health systems in transition Portugalviii
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List of abb
reviations
List of abbreviations
ACES Groups of primary care centres
ACS High Commissariat for Health
ACSS Central Administration of the Health System
ADFA Health subsystem for the Air Force
ADMA Health subsystem for the Navy
ADME Health subsystem for the Army
ADSE Health subsystem for civil servants
ALOS Average length of stay
APIFARMA Association of Pharmaceutical Companies
ASST Authority for Blood and Transplantation Services
CNS National Health Council
CODU Urgent Patients Orientation Centre
CODU-Mar Urgent Patients Orientation Centre for situations occurring at sea
CRSul Rehabilitation Centre at São Brás de Alportel
CT Computerized (axial) tomography
DALE Disability-adjusted life expectancy
DGH Directorate-General of Health
DMFT Decayed, missing or filled teeth
DRG Diagnosis-related group
ERDF European Regional Development Fund
EU European Union
EU15 EU Member States before May 2004
EU25 EU Member States before January 2007
EU27 EU Member States after January 2007
FNAM National Medical Federation
GDP Gross domestic product
GP General practitioner
GPEARI High Commissioner for Health
HiT Health Systems in Transition
HIV/AIDS Human immunodeficiency virus/Acquired immunodeficiency syndrome
Health systems in transition Portugalx
HRA Health Regulatory Agency
HTA Health technology assessment
IDT National Institute of Drug Addiction
IGAS General Inspectorate of Health-related Activities
IGIF Institute for the Financial Administration of Health
INE National Statistics Institute
INEM National Institute for Medical Emergencies
INFARMED National Authority of Medicines and Health Products
INSA National Institute of Health Dr Ricardo Jorge
IPS Portuguese Blood Institute
IQS Institute for Quality
IT Information technology
MRI Magnetic resonance imaging
NHS National Health Service
NUTS Nomeclature of Territorial Units for Statistics
OECD Organisation for Economic Co-operation and Development
OMD Medical Dentists Federation
ONSA National Health Observatory
OOP Out-of-pocket (payments)
OTC Over-the-counter (pharmaceuticals)
PET Positron emission tomography
PIDDAC Central Administration’s Investment and Development Plan
PPPs Public–private partnerships
PT-ACS Health subsystem for workers of Portugal Telecom
PYLL Potential years of life lost
R&D Research and development
RHA Regional Health Administration
RNCCI National Long-term Care Network
SAD GNR Health subsystem for National Republican Guards
SAD PSP Health subsystem for Police Agents
SAMS Health subsystem for banking and associated insurance employees
SDR Standardized death rate
SG General Secretariat of Health
SIGIC System for management of (waiting list) patients waiting for surgery
SIM Independent Medical Union
SSMJ Health subsystem for employees of the Ministry of Justice
TB Tuberculosis
USF Family health unit
VHI Voluntary health insurance
WHO World Health Organization
WPU Weighted production units
List of tables an
d figures
List of tables and figures
Tables page
Table 1.1 Population/demographic indicators, 1970 to latest available year 4
Table 1.2 Macroeconomic indicators, latest available year 5
Table 1.3 Mortality and health indicators, 1970–2008 (selected years) 7
Table 1.4 Maternal and child health indicators, 1970–2009 (selected years) 8
Table 1.5 Infant mortality rates (per 1 000 live births) by region, 2000–2008 (selected years) 8
Table 1.6 Main causes of death – percentage of total number of deaths, 1990–2009 (selected years) 10
Table 1.7 Main causes of death (standardized mortality rate per 100 000 population), 2005–2008 10
Table 1.8 DALE (years), 1999–2002 11
Table 1.9 WHO Health for All immunization categories (percentage of children under 3 years), 2008 12
Table 1.10 Major factors affecting health status, 2001 and 2006 14
Table 1.11 Oral health, 2002–2006 14
Table 2.1 The health care system: historical background and recent reform trends – timeline 18
Table 3.1 Trends in health expenditure, 2000 to latest available year 52
Table 3.2 Funding mix for the health system (%), 2000–2008 (selected years) 59
Table 3.3 User charges for health services 63
Table 4.1 Number of beds in acute care, specialized hospitals, primary care centres and long-term care institutions in Portugal per 100 000 population, 1995–2008 (selected years) 80
Table 4.2 Operating indicators in Portugal and selected countries, 1990–2007 (selected years) 81
Table 4.3 PPPs in Portugal 83
Table 4.4 Health care personnel, 1990–2008 (selected years) 86
Table 4.5 Foreign physicians working for the NHS, 2004–2007 89
Table 5.1 Number of beds in the long-term care network, 2007–2008 114
Table 6.1 Major policy measures, 2000–2009 120
Health systems in transition Portugalxii
Figures page
Fig. 1.1 Levels of immunization for measles in the WHO European Region (%), 2009 or latest available year 13
Fig. 2.1 Overview chart of the health system 16
Fig. 2.2 Organizational chart of the Ministry of Health 24
Fig. 3.1 Financial flows 53
Fig. 3.2 Health expenditure as a share (%) of GDP in the WHO European Region, 2008 54
Fig. 3.3 Trends in health expenditure as a share (%) of GDP in Portugal and selected countries, 1995–2008 55
Fig. 3.4 Health expenditure in US$ PPP per capita in the WHO European Region, 2008 56
Fig. 3.5 Public sector health expenditure as a share (%) of total health expenditure in the WHO European Region, 2008 57
Fig. 4.1 Beds in acute hospitals per 100 000 population in Portugal and selected countries, 1990–2008 80
Fig. 4.2 Number of physicians per 100 000 population in Portugal and selected countries, 1990 to latest available year 86
Fig. 4.3 Number of nurses per 100 000 population in Portugal and selected countries, 1990 to latest available year 87
Fig. 4.4 Number of physicians and nurses per 100 000 population in the WHO European Region, 2009 or latest available year 88
Fig. 4.5 Number of dentists per 100 000 population in Portugal and selected countries, 1990 to latest available year 89
Fig. 4.6 Number of pharmacists per 100 000 population in Portugal and selected countries, 1990 to latest available year 91
Fig. 5.1 Outpatient contacts per person per year in the WHO European Region, 2009 or latest available year 99
Fig. 9.1 Life expectancy at birth, 1990–2003 138
Fig. 9.2 Life expectancy at birth – forecast, 1990–2030 138
Fig. 9.3 Life expectancy at age 65 – forecast, 1990–2030 139
Fig. 9.4 PYLL, 1990–2003 140
Fig. 9.5 PYLL – forecast, 1990–2030 141
Fig. 9.6 PYLL – health care promotion, 1990–2003 142
Fig. 9.7 PYLL – selected causes, forecast, 1990–2030 142
Fig. 9.8 PYLL – scenarios, 1990–2030 143
Fig. 9.9 PYLL – land transport accidents, 1990–2030 144
Fig. 9.10 SDR – per 100 000 population, 1990–2003 145
Fig. 9.11 SDR – selected causes, forecast, 1990–2030 145
Fig. 9.12 SDR – scenarios, 1990–2030 146
Ab
stract
Abstract
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Execu
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Executive summary
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1. Introduction
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1.1 Geography and sociodemography
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Health systems in transition Portugal 3
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Health systems in transition Portugal4
Table 1.1Population/demographic indicators, 1970 to latest available year
1970 1980 1990 2000 2005 2009
Age dependency ratio (dependants to working-age population) 0.61 0.59 0.51 0.48 0.49 0.49
Birth rate, crude (per 1 000 people) 20.8 16.2 11.7 11.7 10.4 9.4
Death rate, crude (per 1 000 people) 10.7 9.7 10.3 10.3 10.2 9.8
Fertility rate, total (births per woman) 3.0 2.25 1.57 1.56 1.41 1.32
Population, ages 0–14 (% of total) 28.5 25.8 20.4 16.1 15.6 15.2
Population, ages 15–64 (% of total) 61.8 62.9 66.2 67.7 67.3 67.0
Population, ages 65 and above (% of total) 9.7 11.3 13.4 16.2 17.1 17.8
Population density (people per km2) 94.37 106.18 108.49 111.18 114.66 113.90a
Population growth (annual %) !0.35 1.05 !0.26 0.62 0.40 0.10
Population, female (% of total) 52.4 51.9 51.8 51.7 51.6 51.6
Population, total (000s) 8 681 9 766 9 983 10 223 10 549 10 633
Urban population (% of total) 38.8 42.8 47.9 54.4 57.6 58.2b
Proportion of single-person households (%) – – 4.0 5.5 – –
Educational level – 9 years of school (%) 14.4 25.8 54.0 83.9 82.5 86.5c
Sources : Data from INE; United Nations, 2009; World Bank, 2009; CIA, 2011.Notes : a2008; b2006; c2007.
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1.2 Economic context
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Health systems in transition Portugal 5
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Table 1.2Macroeconomic indicators, latest available year
Year
GDP (constant LCU) (million €) 163 051.6 2009
GDP per capita, PPP (constant 2000 international $) 18 000 2004
GDP per capita (constant LCU) 12 421 2008
GDP, PPP (constant 2000 international $, in billions) 189 2004
GDP growth (last 10 years average %) 1.16 2009
GINI Index 38.5 2007
Overall general government balance, excluding temporary measures (%GDP) !9.3 2009
Agriculture, value added (% of GDP) 3 2007
Industry, value added (% of GDP) 24 2007
Manufacturing, value added (% of GDP) 73 2007
Current account balance (% of GDP) !7.6 2009
Labour force, total 5 582 700 2009
Unemployment, total (% of total labour force) 9.5 2009
Official exchange rate (US$, €, period average) 1.39 2009
Nominal short-run interest rate (%) 1.2 2009
Nominal long-run interest rate (%) 4.3 2009
Inflation rate !0.8 2009
Sources : Government of the Republic of Portugal, 2009; World Bank, 2009; INE, 2009e; Portuguese Central Bank, 2009.Notes : LCU: Local currency unit; PPP: Purchasing power parity.
Health systems in transition Portugal6
1.3 Political context
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Health systems in transition Portugal 7
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1.4 Health status
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Table 1.3Mortality and health indicators, 1970–2008 (selected years)
1970 1980 1990 2000 2007 2008
Life expectancy at birth, female (years) 70.3 74.6 77.6 80.3 81.6 81.4
Life expectancy at birth, male (years) 64.0 67.5 70.6 73.2 74.9 74.9
Life expectancy at birth, total (years) 67.1 71.2 74.1 76.8 78.3 78.2
Mortality rate (per 1 000 female adults) 10.1 9.0 9.6 9.5 9.2 9.3
Mortality rate (per 1 000 male adults) 11.5 10.6 11.1 11.1 10.4 10.4
Mortality rate, crude (per 1 000) 10.7 9.7 10.3 10.3 9.8 9.8
Infant deaths per 1 000 live births 55.5 24.3 10.9 5.5 3.4 3.3
Probability of dying before age 5 years (per 1 000 live births) – 29.2 14.0 7.3 4.2 4.0
Sources : INE, 2009a, 2009b, 2009c, 2009e; WHO Regional Office for Europe, 2010.
Health systems in transition Portugal8
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Table 1.4Maternal and child health indicators, 1970–2009 (selected years)
1970 1980 1990 2000 2008 2009
Perinatal mortality rate (per 1 000 live births)a – 23.8 12.4 6.4 4.4 4.6
Neonatal mortality rate (per 1 000 live births)a – 15.4 6.9 3.4 2.1 2.5
Fertility indexb 3.0 2.3 1.6 1.6 1.4 1.4
Maternal death (per 100 000 live births)c 73.4 19.0 10.3 2.5 3.8 3.8
Adolescent pregnancy rates (age<20) (per 100 live births)b – – – – 4.2 4.2
Sources : a INE, 2009g; b INE, 2009a; c INE, 2009f, 2009g.
Table 1.5Infant mortality rates (per 1 000 live births) by region, 2000–2008 (selected years)
2000 2004 2005 2006 2007 2008
Continent 5.3 3.8 3.4 3.3 3.4 3.3
North 5.8 4.0 3.8 3.1 3.5 3.6
Centre 4.5 3.2 2.8 3.0 2.8 2.6
Lisbon 5.0 3.9 3.3 3.4 3.5 3.7
Alentejo 5.3 3.4 3.5 3.1 3.7 3.8
Algarve 5.5 4.2 3.6 5.0 3.9 3.2
Source : ACS–Ministry of Health, 2009.
Health systems in transition Portugal 9
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Health systems in transition Portugal10
Table 1.6Main causes of death – percentage of total number of deaths, 1990–2009 (selected years)
1990 1995 2000 2005 2006 2007 2008 2009
Diseases of the circulatory system 44.2 41.9 38.7 34.0 32.2 32.9 32.3 31.9
Malignant neoplasms 17.7 19.3 20.3 21.1 21.7 22.6 23.0 23.2
Diseases of the respiratory system 7.3 7.7 9.7 10.5 11.3 10.6 11.1 11.7
Diseases of the digestive system 4.5 4.4 3.9 4.3 4.2 4.4 4.4 4.4
Diabetes mellitus 2.6 3.0 3.0 4.3 3.7 4.2 4.1 4.4
Source : INE, 2009g.
Table 1.7Main causes of death (standardized mortality ratea per 100 000 population), 2005–2008
2005 2006 2007 2008
Diseases of the circulatory system 211.7 186.5 187.6 181.2
Cerebrovascular diseases 92.5 80.7 80.8 77.1
Ischaemic heart disease 52.6 46.1 46.8 44.0
Malignant neoplasms 155.7 149.7 154.6 155.4
Stomach 16.5 15.1 15.4 16.1
Lung 22.9 23.8 23.1 23.3
Breast 19.9 20.1 18.9 19.8
Prostate 23.3 23.4 22.8 23.1
Diseases of the respiratory system 64.3 63.9 58.9 60.4
Diseases of the digestive system 31.8 29.1 30.2 29.4
Diabetes mellitus 27.2 21.5 24.8 23.5
Land transport accidents 11.7 9.1 9.3 8.5
External cause of deathb 35.7 35.2 33.2 33.2
Total 673.9 629.3 623.1 613.0
Source : INE, 2009g.Notes : a The standardized mortality rate is computed for all ages based on the standardized European population; b Currently a DGH project is under way to improve information on causes of death, which should improve accuracy. Future data may show a detailed picture of the main causes of death in Portugal.
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Health systems in transition Portugal 11
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Table 1.8DALE (years), 1999–2002
1999 2000 2001 2002
Countries MF M F MF M F MF M F MF M F
Portugal 69 66 73 67 64 69 67 64 69 69 67 72
Spain 73 70 76 71 69 63 71 69 73 73 70 76
United Kingdom 72 70 74 69 68 70 70 68 70 71 69 72
EU15 72 – – 70 – – 70 – – 72 – –
Source : WHO Regional Office for Europe, 2010.
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Health systems in transition Portugal12
Table 1.9WHO Health for All immunization categories (percentage of children under 3 years), 2008
Category %
Infants vaccinated against
TB 98.3
Diphtheria 96.8
Tetanus 96.8
Pertussis 96.8
Poliomyelitis 96.9
Hepatitis B 96.8
Rubella 96.6
Children vaccinated against measles 96.6
Infants vaccinated against invasive disease due to haemophilius influenza type B 96.8
Source : WHO Regional Office for Europe, 2010.
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Health systems in transition Portugal 13
Fig. 1.1 Levels of immunization for measles in the WHO European Region (%), 2009 or latest available year
Source : WHO Regional Office for Europe, 2011.Notes : CIS: Commonwealth of Independent States; CARK: Central Asian republics and Kazakhstan.
0 20 40 60 80 100Austria
MaltaGeorgia
DenmarkMontenegro
United KingdomSwitzerlandItaly (2006)
CyprusTajikistan
FranceIreland
Republic of MoldovaEU members before May 2004
EUR-ANorway
IsraelIceland
San MarinoEU
Bosnia and HerzegovinaBelgium
Ukraine (2008)WHO European Region
SloveniaSerbia
PortugalEstonia
UzbekistanCroatia (2008)
LatviaThe former Yugoslav Republic of Macedonia
GermanyLithuaniaArmeniaBulgaria
NetherlandsLuxembourg
CARKSweden
Czech Republic (2004)CIS
TurkeyAlbania
EUR-B+CRomania (2007)
SpainEU members since 2004 or 2007
AndorraPoland
AzerbaijanRussian Federation
FinlandBelarus
KyrgyzstanGreece
SlovakiaMonaco (2004)
KazakhstanTurkmenistan
Hungary 99.899.4 99.0 99.0 99.0
98.7 98.7
98.6 98.3 98.3 97.54 98 97.8 97.8 97.3 97.1 96.93 97 97 96.9 96.6 96.6 96.5 96.296.2 96.2 96.096.0
95.595.9
95.4
95.0
95.0
97.5 97.1 97.0 97.0 97.0 96.9 96.9 96.7 96.2 96.2 96.2 96.1 96.0 96.0 95.9 95.8 95.7
95.0 95.0
95.595.4
95.0 95.095.0 94.4994.5 94.3 94.0 93.0 92.9 92.9
92.0 92.0 92.0
91.3
91.891.7
90.4 90.1
89.2 87.0 87.0 87.0
86.0 85.9
84.0 82.7
98.5 98.7 98.7 98.8 98.7 98.7 98.9 98.7 98.7 98.9
98.7 98.7 98.5 98.3 98.3 98.0 97.5
82.0 76.076.0
Health systems in transition Portugal14
FDUH�DFFHVV�DQG�TXDOLW\��7KHVH�IDFWRUV�DUH�PRVW�OLNHO\�GXH�WR�WKH�HYROXWLRQ�RI�WKH�SULPDU\�DQG�ORQJ�WHUP�FDUH�QHWZRUNV��DV�ZHOO�DV�WKH�UHFHQW�HQIRUFHPHQW�RI�WKH�1DWLRQDO�+HDOWK�3ODQ��&KDSWHU���SUHVHQWV�WKH�UHVXOWV�RI�D�SURVSHFWLYH�DQDO\VLV�RI�3RUWXJXHVH�KHDOWK�VWDWXV��
Table 1.10Major factors affecting health status, 2001 and 2006
2001 2006
M F M F
Youth
Tobacco – % of individuals who smoke daily (15–24 years) 25.7 10.6 25.9 14.2
Alcohol – % of individuals who consumed alcohol in the last 12 months (15–24 years)
48.7 25.5 50.1 35.2
Weight – % of individuals with body mass index between 27 and 29.9 (18–24 years)
6.6 4.5 9.4 6.0
Obesity – % of individuals with body mass index *30 (18–24 years) 3.0 2.3 4.2 3.4
Adults
Tobacco – % of smoking individuals (25–44 years) 45.6 17.3 37.6 17.5
Tobacco – % of smoking individuals (45–64 years) 26.8 4.5 25.5 8.4
Alcohol – % of individuals who consumed alcohol in the last 12 months (25–44 years)
86.0 54.1 82.0 54.0
Alcohol – % of individuals who consumed alcohol in the last 12 months (45–64 years)
87.8 48.6 89.2 57.6
Weight – % of individuals with body mass index between 27 and 29.9 (35–44 years)
22.1 16.3 19.8 14.4
Weight – % of individuals with body mass index between 27 and 29.9 (55–64 years)
25.5 22.1 25.4 25.3
Obesity – % of individuals with body mass index *30 (35–44 years) 11.3 11.6 12.8 12.7
Older adults
Tobacco – % of smoking individuals (65–74 years) 14.4 0.9 12.1 1.3
Alcohol – % of individuals who consumed alcohol in the last 12 months (65–74 years)
78.6 38.7 81.7 43.7
Weight – % of individuals with body mass index between 27 and 29.9 (65–74 years)
26.3 21.6 26.4 22.3
Obesity – % of individuals with body mass index *30 (55–64 years) 16.2 20.3 22.0 24.3
Obesity – % of individuals with body mass index *30 (65–74 years) 14.5 19.5 19.6 23.5
Source : ACS–Ministry of Health, 2009.
Table 1.11Oral health, 2002–2006
2002/2003 2004/2005 2005/2006
Decayed, missing or filled teeth (DMFT) at age 12 (%) 3.0 1.5 1.5
Young people in need of dental treatment at age 12 (%) 18.0 43.0 44.0
6-year-old children with no dental decay (%) 33.0 50.0 51.0
Source : ACS–Ministry of Health, 2009.
2. Org
anization an
d govern
ance
2. Organization and governance
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Health systems in transition Portugal16
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2.1 Overview of the health system
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Fig. 2.1Overview chart of the health system
Direct and indirecttaxes (compulsory,
income-basedcontributions)
Payrollcontributions
Direct financing
Capital expenditure
Capital expenditureand salary + other payments
Conventioned sectorService flow
User charges
OOP payments
Reimbursementof non-NHS users
Regulated prices
DRG-basedpricing system
Agreement paymentsFee-for-service
Voluntaryrisk-ratedpremiums
Historical andactivity-based budget
Opting-out payments forsome subsystem users
Centralgovernment
Healthsubsystems
Pharmacies
Familyhealthunits
(USFs)
Healthcentres(public)
Publichospitals
Privatehospitals
Privateambulatory
care
Privateinsurance
funds
Populationand
companies
Patients
Ministryof Health
RHAs(public
insurers)
Moving towardsprospectivepaymentestablished byyearly negotiatedcontracts
Contract-based payments or fee-for-serviceService flow
Direct or prospective paymentsRetrospective payments
Health systems in transition Portugal 17
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2.2 Historical background
,Q�RUGHU�WR�XQGHUVWDQG�3RUWXJDO¶V�FRPSOH[�KHDOWK�FDUH�V\VWHP��LW�LV�LPSRUWDQW�WR�H[DPLQH�VRPH�RI�WKH�PDLQ�KLVWRULFDO�IDFWRUV�WKDW�KDYH�LQIOXHQFHG�LWV�GHYHORSPHQW��7DEOH�����VXPPDUL]HV�WKH�NH\�UHIRUPV�WKDW�KDYH�VKDSHG�WKH�GHYHORSPHQW�RI�KHDOWK�FDUH�LQ�3RUWXJDO�RYHU�WKH�SDVW�FHQWXU\��3ULRU�WR�WKH���WK�FHQWXU\��KHDOWK�FDUH�ZDV�SURYLGHG�IRU�WKH�SRRU�RQO\�E\�WKH�KRVSLWDOV�RI�UHOLJLRXV�FKDULWLHV�FDOOHG�0LVHULFyUGLDV��VHH�VXEVHFWLRQ�0LVHULFyUGLDV�LQ�VHFWLRQ�������ZKLFK�DUH�VWLOO�ILUVW�DQG�IRUHPRVW�UHOLJLRXVO\�DIILOLDWHG�LQVWLWXWLRQV��'XULQJ�WKH���WK�FHQWXU\��WKH�VWDWH�HVWDEOLVKHG�D�OLPLWHG�QXPEHU�RI�WHDFKLQJ�KRVSLWDOV�DQG�SXEOLF�KRVSLWDOV�WR�VXSSOHPHQW�WKLV�FKDULWDEOH�SURYLVLRQ��7KLV�ZDV�IXUWKHU�H[WHQGHG�LQ������ZLWK�WKH�DSSRLQWPHQW�RI�VDODULHG�PXQLFLSDO�GRFWRUV�ZKR�SURYLGHG�FXUDWLYH�VHUYLFHV�WR�WKH�SRRU��7KH�GHYHORSPHQW�RI�SXEOLF�KHDOWK�VHUYLFHV�GLG�QRW�EHJLQ�XQWLO�������7KH�ILUVW�SXEOLF�KHDOWK�OHJLVODWLRQ�DFW�LQ������HQDEOHG�WKH�FUHDWLRQ�RI�D�QHWZRUN�RI�PHGLFDO�RIILFHUV�UHVSRQVLEOH�IRU�SXEOLF�KHDOWK��$�IXUWKHU�SXEOLF�KHDOWK�ODZ�ZDV�LQWURGXFHG�LQ�������ZKLFK�HVWDEOLVKHG�SXEOLF�PDWHUQLW\�DQG�FKLOG�ZHOIDUH�VHUYLFHV��,W�ZDV�DOVR�XQGHU�WKLV�ODZ�WKDW�WKH�QDWLRQDO�SURJUDPPHV�IRU�7%��OHSURV\�DQG�PHQWDO�KHDOWK��ZKLFK�ZHUH�DOUHDG\�RSHUDWLQJ��ZHUH�OHJDOO\�HVWDEOLVKHG��%DUURV��6LP}HV��������
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Health systems in transition Portugal18
Table 2.1The health care system: historical background and recent reform trends – timeline
1901 The first act of public health legislation was published, whereby a network of medical officers responsible for public health was created. It followed the international trend set by several institutions, which tried to develop the basis of the public health movement. This is thought to be the root of “modern sanitarism” (Ricardo Jorge reform).
1940 The first (specific) Health Department within the Ministry of Internal Affairs was established.
1944 The Social Services Statute was published, comprising a “minimum state intervention” principle in the social arena.
1945 Public maternity and child welfare services were established. Vertically organized national institutes and programmes for TB, leprosy and mental health, which were already operating, were also legally established.
1946 The law was passed that laid the groundwork for hospital organization and the promotion of new hospital buildings, financed by government funds, but run by Misericórdias. Hospital regionalization was initiated. Hospitals were to reorganize into three levels, namely municipality, district and region, ensuring technical cooperation among them.
A mandatory social health insurance system for a limited number of professions was created: the Caixas de Previdência.
1958 The Ministry of Health and Assistance was created.
1963 Statute of Health and Assistance, according to which the state is obliged to co-finance the installation and functioning of health facilities.
1968 The Hospitals Regulatory Act defined the nature and attributions of hospital care.
1971 The state was acknowledged to be responsible for health policy and implementation, for the integration of health activities, and for investment in disease prevention and health promotion. Citizens’ right to health was also recognized. Primary care centres were created.
1974 The democratic revolution occurred on 25 April, which ended a long period of right-wing political dictatorship. As a result, health services administration was taken from private holders that had been financed mainly by public funds, aiming to give the whole population access to health care, irrespective of ability to pay.
1976 The Portuguese Constitution was approved, which embodied citizens’ right to health care. It recognizes citizens’ right to health care by “the creation of a universal, free-of-charge National Health System”.
1979 The NHS Law created a universal health system, free at the point of use.
1982 The career of general practitioners (GPs)/family doctors was created.
1988 The Law on Hospital Management established guiding principles for NHS hospitals, including entrepreneurial management, decentralization of decision-making through intermediate responsibility centres and nomination of management boards by the government.
1989 The first pricing list based on DRGs was issued for third-party payers with respect to NHS hospital inpatient use by their beneficiaries. The Portuguese Constitution was reviewed, and now states that the “National Health Service is universal and tends to be free of charge, taking into account citizens’ social and economic conditions”.
1990 The Law on the Fundamental Principles of Health introduced new principles for the organization and functioning of the health system. Inter alia, an explicit role was assigned to the private profit-making and non-profit-making sectors through contracting with the NHS; the system’s operation and management was decentralized to the regional level and user charges were introduced for ambulatory services.
Private practice was allowed in public hospitals, under certain conditions related to the seniority and position of physicians as well as to the status of exclusive employment in the NHS. Private financing of health care was allowed, and incentives for private health insurance were given. The possibility of creating an alternative health insurance system was also approved.
1993 The Statute of the NHS was published in order to accommodate the changes introduced by the Law of Fundamental Principles of Health in 1990, namely the decentralization of the health system, the integration of primary care centres and hospitals in health units and the contracting out of NHS services.
The new internal organization of the Ministry of Health was published. A Decree on the statutory regulation of private health entities was issued in order to ensure the accomplishment of quality standards. Five RHAs (Administração Regional de Saúde) were established.
1995 The first attempt at putting an NHS hospital under the management control of a private consortium was initiated with the launch of a public bid for proposals according to a set of predefined terms.
Health systems in transition Portugal 19
1997 Contracting agencies (initially named accompanying agencies) were created – one in each RHA – with the overall aim of providing the basis for the payment and provider split within the NHS. The contracting agencies should also promote means of citizens’ participation in health decision-making.
1998 An experimental payment system for GPs working at primary care centres was introduced. The intention was to pay according to capitation and performance, instead of the traditional payment by fixed salary. Enrolment in this experimental system was voluntary.
The National List of Health Equipment was published for the first time. A law on the principles of mental health policy was published, whereby community care is given priority over institutional care under different arrangements. The law also regulated the compulsory inpatient status of individuals with mental illness.
1999 The National Health Strategy and goals for the period 1998–2002, involving a broad range of social partners, was published as a revised version of an internal document issued in 1998. Legislation was passed creating local health systems and reforming primary care centres. Local health systems were integrated into frameworks for hospitals, primary care centres and other health care provider entities. Primary health care reform was based on financially autonomous primary care centres, with networks of primary health care teams. This legislation was not implemented.
The Local Health Unit of Matosinhos became the first example of effective integration of local hospitals and related primary care centres into a unique provider entity. A law was approved in Parliament to fund a special programme to reduce waiting lists for surgical procedures at NHS hospitals. The contracting out of non-NHS entities was allowed only after internal capacity was fully used. Responsibility Centres in hospitals were set up as a means of establishing intermediate management levels and promoting decentralization of authority and of responsibility, in order to achieve higher levels of efficiency in the NHS.
2000 The use of an NHS Identity Card became mandatory.
2001 Regulations for the licensing and evaluation of private clinics and dentists’ private practices were published.
2002 A framework for the implementation of PPPs for the building, maintenance and operation of health facilities was created, along with the identification of the basic principles and instruments. A new law on the management of hospitals was issued to enable the changeover of some institutions into public enterprises. A total of 34 hospitals, corresponding to approximately 40% of all NHS hospitals, were transformed into public enterprises.
A Decree established NHS drugs prescription using the common international denomination (International Nonproprietary Name, INN) as obligatory, as well as the conditions under which prescribed brands can be substituted by generics when dispensing. Reference prices for pharmaceuticals were introduced to cap state co-payment levels.
2003 The Health Regulatory Agency (HRA) was created to ensure that citizens have access to health care and to guarantee competition among health care providers.
2004 The National Health Plan for 2004–2010 was approved.
2005 A law was passed allowing the selling of over-the-counter (OTC) products in other authorized establishments (i.e. outside pharmacies).
The number of hospitals transformed into public enterprises was increased. A new legal statute was adopted to signal that there was no intention of privatization.
2006 Family health units (USFs) were created. The goal is to bring GPs closer to patients. The GP payment system depends on their performance and on the case-mix of their patients.
2007 The values of co-payments were updated. Co-payment was expanded to ambulatory surgery and hospital admission. The prices of pharmaceutical products decreased for the second consecutive year, by administrative ruling. A major restructuring of the Ministry of Health is under way.
2008 The Charter of patients’ rights to access health care was published. An administrative ruling lowers the maximum price of generic drugs.
2009 The Ministry of Health approved the National Strategy on Quality in Health Care. Hospitals are allowed to host pharmacies (other than the hospital pharmaceutical department). The co-payment on inpatient admissions is abolished.
2010 The Ministry of Health set the new paediatric age at up to 18 years old. All the hospitals are forced to present a plan to reduce expenses, due to the economic crisis in the country. The shortage of physicians leads to the hiring of retired physicians by the Ministry of Health. The prescription of unit dose pharmaceuticals is approved. The Ministry of Health nominates the Group for the Primary Health Care Reform, together with the new governance model for the reform.
Health systems in transition Portugal20
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Health systems in transition Portugal 23
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2.3 Organizational overview
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2.3.1 Ministry of Health
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Health systems in transition Portugal24
Fig. 2.2Organizational chart of the Ministry of Health
Note : Dotted lines represent some degree of independence from the Ministry of Health.
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Ministerof Health
Health Secretaryof State
Adjunct HealthSecretary of State
National HealthCouncil (CNS)
Health RegulatoryAgency (HRA)
Directadministration
High Commissariatfor Health (ACS)
General Inspectorate ofHealth-related Activities
(IGAS)
Directorate-Generalof Health (DGH)
Authority for Bloodand Transplantation
Services (ASST)
General Secretariatof Health (SG)
Central Administrationof the
Health System (ACSS)
PortugueseBlood Institute (IPS)
Regional healthadministrations (RHAs)
National Institute ofDrug Addiction (IDT)
National Authorityof Medicines andHealth Products
(INFARMED)
National Institutefor Medical
Emergencies (INEM)
Long-termintegrated care
Partnershipson health
National Instituteof Health
Dr Ricardo Jorge(INSA)
Indirectadministration
Missionstructures
Health systems in transition Portugal 25
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2.3.2 Ministry of Finance
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2.3.7 Misericórdias
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Health systems in transition Portugal 31
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2.3.8 Private health insurance companies
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2.3.9 Professional associations and unions
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2.3.10 Patient groups
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2.4 Decentralization and centralization
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Health systems in transition Portugal 33
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2.5 Planning
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Health systems in transition Portugal 35
2.6 Health information management
2.6.1 Information systems
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Health systems in transition Portugal36
2.6.2 HTA
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2.7 Regulation
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2.7.2 Regulation and governance of providers
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2.7.4 Regulation and governance of pharmaceutical care
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2.7.5 Regulation and governance of medical devices
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2.7.6 Regulation of capital investment
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2.8 Patient empowerment
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2.8.1 Patient information
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2.8.2 Patient choice
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2.8.3 Patient rights
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2.8.4 Complaints procedures
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2.8.5 Public participation
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2.8.6 Patients and cross-border care
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3. Financing
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3.1 Health expenditure
7DEOH�����VKRZV�WKH�SHUFHQWDJH�RI�WRWDO�KHDOWK�H[SHQGLWXUH�ILQDQFHG�WKURXJK�SXEOLF�DQG�SULYDWH�VRXUFHV��3XEOLF�H[SHQGLWXUH��ZKLFK�FRPHV�PDLQO\�IURP�WD[DWLRQ��RYHU�������LQFOXGHV�IXQGLQJ�RI�GLUHFW�FDUH�SURYLVLRQ�ZLWKLQ�WKH�1+6�DQG�VXEVLGLHV�WR�WKH�KHDOWK�VXEV\VWHPV�IRU�SXEOLF�VHFWRU�HPSOR\HHV��3ULYDWH�H[SHQGLWXUH�PDLQO\�LQFOXGHV�223�SD\PHQWV�DQG�9+,���6HH�)LJ������IRU�D�EURDG�SLFWXUH�RI�WKH�ILQDQFLDO�IORZV��
Table 3.1Trends in health expenditure, 2000 to latest available year
2000 2005 2006 2007 2008
Total health expenditure in € per capita 1 012.0 1 367.4 1 394.6 1 440.5 –
Total health expenditure as % of GDP 8.5 9.7 9.5 9.4 –
Public expenditure on health as % of total health expenditure 72.9 71.4 71.2 69.8 –
Private expenditure on health as % of total health expenditure 27.1 28.6 28.8 30.2 –
Mean annual real growth rate in GDP (base: 2000) 3.95 0.94 1.40 1.87 !0.02
Total government spending as % of GDP 41.9 45.1 46.3 45.8 46.1
Government health spending as % of total government spending 12.7 10.5 9.95 6.87 7.06
Government health spending as % of GDP 4.3 6.3 5.9 5.5 5.5
OOP payments as % of total health expenditure 23.2 23.9 23.1 – –
Sources : INE, 2010; Ministry of Finance & Ministry of Internal Affairs, 2000–2008. Note : Data are also available at http://www.pordata.pt/.
223�SD\PHQWV�LQ�3RUWXJDO�DUH�HVWLPDWHG�WR�EH�DPRQJ�WKH�KLJKHVW�LQ�(XURSH��7KH\�DFFRXQWHG�IRU�DSSUR[LPDWHO\�������RI�WRWDO�KHDOWK�H[SHQGLWXUH�LQ������DQG�KDYH�EHHQ�VOLJKWO\�DERYH�����VLQFH�������VHH�VHFWLRQ�������)ROORZLQJ�WKH�FRQFOXVLRQV�RI�LQWHUQDWLRQDO�VWXGLHV��VHH�:DJVWDII�HW�DO����������RQH�PD\�VWDWH�WKDW��RYHUDOO��WKH�WKHRUHWLFDOO\�SURJUHVVLYH�UHGLVWULEXWLYH�LQFRPH�WD[�V\VWHP�LQ�3RUWXJDO�WXUQV�RXW�WR�EH�VOLJKWO\�UHJUHVVLYH�LQ�KHDOWK�FDUH�ILQDQFLQJ�GXH�WR�D�KLJK�VKDUH�RI�223�SD\PHQWV�DORQJ�ZLWK�D�KHDY\�UHOLDQFH�RQ�LQGLUHFW�WD[HV��,QGLUHFW�WD[HV�RQ�JRRGV�DQG�VHUYLFHV�DFFRXQW�IRU�������RI�WRWDO�JRYHUQPHQW�UHYHQXH�LQ�������7KH�H[LVWHQFH�RI�D�JHQHURXV��E\�LQWHUQDWLRQDO�VWDQGDUGV��V\VWHP�RI�WD[�EHQHILWV�WR�SULYDWH�KHDOWK�VSHQGLQJ�DGGV�WR�WKLV�UHJUHVVLYLW\�RI�KHDOWK�FDUH�IXQGLQJ��,Q�RWKHU�ZRUGV��KHDOWK�H[SHQGLWXUH�IDOOV�UHODWLYHO\�PRUH�KHDYLO\�RQ�ORZ�LQFRPH�
Health systems in transition Portugal 53
Fig. 3.1Financial flows
KRXVHKROGV��7KHVH�FRQWULEXWRUV�DUH�OHVV�DEOH�WR�REWDLQ�D�KLJKHU�SHUFHQWDJH�UHIXQG�IURP�WKH�WD[�V\VWHP�WKDQ�WKH�KLJK�LQFRPH�KRXVHKROGV�����YHUVXV������ZKHQ�DQDO\VLQJ�WKH�ORZHU�DQG�XSSHU�JURXSV�RI�WKH�LQFRPH�GLVWULEXWLRQ��
'DWD�SUHVHQWHG�KHUH�RULJLQDWH�IURP�WKH�UHFHQWO\�SXEOLVKHG�1DWLRQDO�+HDOWK�$FFRXQWV��,1(���������FRQVWUXFWHG�LQ�DFFRUGDQFH�ZLWK�:+2�2(&'�SULQFLSOHV�DQG�IURP�WKH�:+2�+HDOWK�IRU�$OO�'DWDEDVH��:+2�5HJLRQDO�2IILFH�IRU�(XURSH���������7RWDO�KHDOWK�FDUH�H[SHQGLWXUH�LQ�3RUWXJDO�KDV�ULVHQ�VWHDGLO\�IURP�DV�OLWWOH�DV����LQ������WR�DOPRVW�����RI�*'3�LQ�������,Q�������KHDOWK�VSHQGLQJ�PDGH�XS�����RI�*'3�LQ�3RUWXJDO��DERYH�WKH�(8���DYHUDJH�RI�����VHH�)LJ��������3RUWXJDO�QRZ�VSHQGV�PRUH�WKDQ�ERWK�,WDO\�DQG�6SDLQ�LQ�WHUPV�RI�SURSRUWLRQ�RI�
Population
Patients
Central government Ministry of Health
Health subsystems
Private insurance funds
RHAs
RHAContracting Agency
Pharmacists
Private clinics/hospitals and
services
Health professionalspublic and
private practices
Primary carecentres
Publichospitals
Contract-based paymentsService flow
Direct or prospective paymentsRetrospective payments
Capitalexpenditure
Salary +other payments
Capitalexpenditure
OOP
paym
ent
Dire
ct a
nd in
dire
ct ta
xes
Volu
ntar
y ris
k-ra
ted
prem
ium
s
Retro
spec
tive
reim
burs
emen
t
Payroll contributionsFee for serviceor per diem
Fee for serviceor per diem
Opting-out
Directfinancing Contract
payment
Contractpayment
Historical andactivity costs budget
ACSS
Health systems in transition Portugal54
Fig. 3.2Health expenditure as a share (%) of GDP in the WHO European Region, 2008
Source : WHO Regional Office for Europe, 2011.Notes : CIS: Commonwealth of Independent States; CARK: Central Asian republics and Kazakhstan.
0 2 4 6 8 10 12 14CARK
CISEur-B+C
EU members since 2004 or 2007WHO European Region
EUEur-A
EU members before May 2004Averages
TurkmenistanAzerbaijan
KazakhstanArmenia
UzbekistanRussian Federation
TajikistanBelarus
KyrgyzstanUkraineGeorgia
Republic of MoldovaCIS
RomaniaEstonia
LithuaniaLatvia
PolandCzech Republic
AlbaniaTFYR Macedonia
BulgariaHungarySlovakiaCroatia
SloveniaMontenegro
SerbiaBosnia and Herzegovina
Central and south-eastern EuropeMonaco
TurkeyCyprus
San MarinoLuxembourg
AndorraMaltaIsrael
FinlandNorwayIrelandSpain
United KingdomItaly
SwedenNetherlands
BelgiumGreece
DenmarkAustria
PortugalGermany
SwitzerlandFranceIceland
10.4
11.110.5
10.1 10.1
9.9
11.8
9.7
7.5
9.8
11.8
9.7 9.7 9.7
9.1 9.1
9.0 9.0
8.78.7
8.68.4
8.07.57.5 7.5
7.27.1
6.75.0
10.3
10.78.7
6.86.6
6.5
5.05.2
4.0
9.69
5.6
9.8 9.5 9.5
7.8 7.8 7.8 7.8 7.8 7.8
7.4 7.4 7.3
7.0 6.9
6.8 6.6
6.5 6.2
5.9 4.7
9.7
5.68 5.7 5.44 5.4
7.56 7.6
9.56 9.6
5.6
3.83.83.73.7
3.63.61.81.8
9.0
4.6
6.4
Western Europe
Health systems in transition Portugal 55
*'3��)LJ��������GHVSLWH�KDYLQJ�VSHQW�FRQVLGHUDEO\�OHVV�WKDQ�WKH\�GLG�LQ�������3RUWXJDO�VSHQGV�DERYH�86�������SHU�FDSLWD��ZKLFK�LV�VOLJKWO\�EHORZ�WKH�(8���DYHUDJH��)LJ��������GHVSLWH�VSHQGLQJ�DOPRVW�WKH�KLJKHVW�DPRXQW�RQ�KHDOWK�FDUH�DV�D�SURSRUWLRQ�RI�*'3�
Fig. 3.3Trends in health expenditure as a share (%) of GDP in Portugal and selected countries, 1995–2008
Source : WHO Regional Office for Europe, 2011.
$V�VKRZQ�LQ�7DEOH������S�������WKH�DPRXQW�VSHQW�RQ�KHDOWK�FDUH�KDV�LQFUHDVHG�LQ�ERWK�DEVROXWH�DQG�UHODWLYH�WHUPV��*URZWK�UDWHV�RI�WRWDO�KHDOWK�H[SHQGLWXUH�VHHP�WR�EH�VORZLQJ�GRZQ��DV�ZHOO�DV�*'3�UDWHV��WKRXJK�WKH\�VWLOO�VKRZ�D�VWHDG\�DQG�VWURQJ�JURZWK�SDWWHUQ��DQG�WKH�SURSRUWLRQ�RI�WRWDO�KHDOWK�H[SHQGLWXUH�RYHU�*'3�KDV�DOVR�LQFUHDVHG��7KH�JURZWK�LQ�WRWDO�KHDOWK�H[SHQGLWXUH�ZDV�PRUH�SURQRXQFHG�LQ�SXEOLF�KHDOWK�H[SHQGLWXUH��ZKLFK�VWHDGLO\�LQFUHDVHG�LWV�VKDUH�RI�H[SHQVHV��'HVSLWH�WKH�LQFUHDVH��SXEOLF�VRXUFHV�RI�VSHQGLQJ�DV�D�SURSRUWLRQ�RI�WRWDO�KHDOWK�H[SHQGLWXUH�DUH�WKH�ORZHVW�DPRQJ�WKH�(8���FRXQWULHV��)LJ��������,W�DSSHDUV�WKDW�3RUWXJDO�KDV�QRW�FRQWDLQHG�KHDOWK�H[SHQGLWXUH�JURZWK�DV�VXFFHVVIXOO\�DV�RWKHU�VRXWKHUQ�(XURSHDQ�FRXQWULHV��2QH�SODXVLEOH�H[SODQDWLRQ�OLHV�LQ�WKH�FRXQWU\¶V�SROLWLFDO�UHOXFWDQFH�WR�LPSRVH�FRVW�FRQWURO�PHDVXUHV�DIWHU�LW�ZDV�DVVXPHG�WKDW�LQYHVWPHQW�ZDV�QHHGHG�LQ�RUGHU�WR�EXLOG�XS�QHZ�IDFLOLWLHV�DQG�WR�SURPRWH�WKH�H[SDQVLRQ�RI�1+6�FRYHUDJH��'L[RQ��0RVVLDORV��������
6
7
8
9
10
11
12
United KingdomSpain
Portugal
Italy
France
20082007200620052004200320022001200019991998199719961995
%
Health systems in transition Portugal56
Fig. 3.4Health expenditure in US$ PPP per capita in the WHO European Region, 2008
Source : WHO Regional Office for Europe, 2011.Notes : PPP: Purchasing power parity; CIS: Commonwealth of Independent States; CARK: Central Asian republics and Kazakhstan.
0 1000 2000 3000 4000 5000 6000 7000CARK
CISEur-B+C
EU members since 2004 or 2007WHO European Region
EUEur-A
EU members before May 2004AveragesTajikistan
TurkmenistanUzbekistanKyrgyzstan
ArmeniaAzerbaijan
Republic of MoldovaKazakhstan
GeorgiaUkraineBelarus
Russian FederationCIS
AlbaniaRomania
The former Yugoslav Republic of MacedoniaSerbia
Bosnia and HerzegovinaBulgaria
LatviaPoland
LithuaniaEstonia
MontenegroHungary
CroatiaCzech Republic
SlovakiaSlovenia
Central and south-eastern EuropeTurkeyIsrael
PortugalMonaco
SpainItaly
GreeceSan Marino
FinlandAndorra
United KingdomCyprus
BelgiumSweden
DenmarkIreland
GermanyNetherlands
FranceAustria
MaltaIceland
SwitzerlandNorway
Luxembourg
4 310
4 989
2 334
3 749
2 852
6 047
3 749 3 692 3 692 3 676 3 676
3 630 3 630 3 423 3 392
3 3123 2303 191
2 9792 962
2 852
2 791 2 791
695 695
2 559 2 559
4 620
3 836
2 825 2 825
4 039
2 288
2 183
318316
498432420
161228
2 877.46
4 620
1 717
867 867
1 496
838 838 702 702
665 665
1 419
866 866800 800
1 319 1 226
1 178 1 1621 112
910
543
2 878
620.25 620 206
729.43 729
1 969
3 3203 281
1 195
120 107
134
Western Europe
3 8363 7783 778
1 717 1 684 1 684
Health systems in transition Portugal 57
Fig. 3.5Public sector health expenditure as a share (%) of total health expenditure in the WHO European Region, 2008
Source : WHO Regional Office for Europe, 2011.Notes : CIS: Commonwealth of Independent States; CARK: Central Asian republics and Kazakhstan.
0 10 20 30 40 50 60 70 80 90 100CARK
CISEur-B+C
WHO European RegionEU members since 2004 or 2007
EUEur-A
EU members before May 2004Averages
GeorgiaAzerbaijanTajikistanArmenia
KyrgyzstanUzbekistan
Republic of MoldovaTurkmenistan
UkraineRussian Federation
KazakhstanBelarus
CISAlbania
BulgariaBosnia and Herzegovina
LatviaMontenegro
SerbiaSlovakiaHungary
The former Yugoslav Republic of MacedoniaPoland
SloveniaLithuania
EstoniaRomania
Czech RepublicCroatia
Central and south-eastern EuropeCyprus
IsraelSwitzerland
GreeceTurkey
AndorraPortugal
SpainBelgiumFinland
MonacoAustria
GermanyItaly
MaltaFranceIreland
SwedenNetherlands
United KingdomNorway
DenmarkSan Marino
IcelandLuxembourg
84.7
70.2
76.8
69.0
91.1
76.876.6 76.6
74.9 74.9 74.8 74.8
82.8 82.182.082.0
79.0
74.372.8
69.0
57.2 57.2
84.9 84.9
45.1 45.1
85.5
77.4
59.0 59.0
84.2
69.9
60.9
50.5
43.7
42.0
54.550.5
20.724.0
77.51
85.5 87.3 87.3
84.7
66.8 66.8
81.0
58.2 58.2 57.8 57.8
75.3 75.3
73.0
65.7 65.765.5 65.5
56.156.1
47.947.9
26.226.2
71.471.070.5 70.3
60.362.5
59.6
77.577.0977.176.5676.6
58.7958.851.6
69.863.0
73.0
Western Europe
77.477.477.4
84.7
78.7 78.7
Health systems in transition Portugal58
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3.2 Sources of revenue and financial flows
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3ULYDWH�KHDOWK�H[SHQGLWXUH�KDV�ZLWQHVVHG�VRPH�JURZWK�LQ�UHFHQW�\HDUV��WKRXJK�DW�D�VORZHU�UDWH�WKDQ�SXEOLF�KHDOWK�H[SHQGLWXUH��$�ODUJH�SURSRUWLRQ�RI�ILQDQFLQJ��DERXW�����RI�WRWDO�H[SHQGLWXUH��LV�SULYDWH��PDLQO\�LQ�WKH�IRUP�RI�223�SD\PHQWV��ERWK�FR�SD\PHQWV�DQG�GLUHFW�SD\PHQWV�E\�WKH�SDWLHQW���DQG�WR�D�OHVVHU�H[WHQW�LQ�WKH�IRUP�RI�SUHPLXPV�WR�SULYDWH�LQVXUDQFH�VFKHPHV�DQG�PXWXDO�LQVWLWXWLRQV��7DEOH�����UHSRUWV�RQ�WKH�PDLQ�SULYDWH�VRXUFHV�RI�ILQDQFLQJ�LQ�WKH�SHULRG�����±������GLVWLQJXLVKLQJ�EHWZHHQ�223�SD\PHQWV��QRQ�SURILW�PDNLQJ�LQVWLWXWLRQV�VHUYLQJ�IDPLOLHV��9+,�DQG�RWKHU�SULYDWH�VRXUFHV��
Health systems in transition Portugal 59
Table 3.2Funding mix for the health system (%), 2000–2008 (selected years)
2000 2005 2006 2007 2008
Public funding 68.8 68.9 66.9 66.6 65.6
Private funding 31.2 31.1 33.1 33.4 34.4
of which
Non-profit-making institutions serving families 0.5 0.4 0.4 0.3 0.3
VHI 11.3 14.2 14.4 14.0 15.0
OOP payments 86.4 84.1 83.9 83.9 83.4
Other private funding 1.8 1.4 1.3 1.3 1.4
Sources : INE, 2010; Ministry of Finance & Ministry of Internal Affairs (2000–2008). Note : Data are also available at http://www.pordata.pt/.
3.3 Overview of the statutory financing system
3.3.1 Coverage
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Health systems in transition Portugal60
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3.3.2 Collection
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Health systems in transition Portugal 61
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3.3.3 Pooling of funds
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7KH�5+$�EXGJHW�IRU�SULPDU\�KHDOWK�FDUH�ZDV�VHW�LQ������RQ�WKH�EDVLV�RI�D�FRPELQDWLRQ�RI�KLVWRULFDO�H[SHQGLWXUH�DQG�FDSLWDWLRQ��7KLV�DSSURDFK�ZDV�LQWURGXFHG�LQ������DQG�WKH�EXGJHW�FRPSXWDWLRQ�KDV�EHHQ�SURJUHVVLYHO\�VNHZHG�WRZDUGV�D�UHODWLYH�LQFUHDVH�RI�WKH�FDSLWDWLRQ�FRPSRQHQW��(DFK�5+$�EXGJHW�UHDFKHG�D�EDODQFH�RI�����IRU�KLVWRULFDO�YDOXHV�DQG�����IRU�FDSLWDWLRQ��,Q�RUGHU�WR�SURYLGH�DQ�DGMXVWPHQW�IRU�KHDOWK�FDUH�QHHGV��WKH�FDSLWDWLRQ�FRPSRQHQW�ZDV�
Health systems in transition Portugal62
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3.3.4 Purchasing and purchaser–provider relations
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Health systems in transition Portugal 63
3.4 OOP payments
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3.4.1 Cost-sharing
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Table 3.3User charges for health services
Health service Type of user charge Exemptions and/or reduced rates
GP visit Co-payment Social security beneficiaries and certain patient groups are exempt from these user charges
Patients over 65 years old were exempt from 50% of the inpatient user charge
Primary care Co-payment
Outpatient specialist visit Co-payment
Outpatient prescription drugs Co-insurance, varies depending on therapeutic value
Inpatient stay (Co-payment removed in 2009)
Dental care
Medical devices
Emergency visit Co-payment
Note : There is no cap on OOP payments.
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Health systems in transition Portugal64
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3.4.2 Direct payments
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3.5 VHI
3.5.1 Market role and size
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3.5.2 Market structure
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3.5.3 Market conduct
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Health systems in transition Portugal 67
3.5.4 Public policy
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3.6 Other financing
3.6.1 Parallel health systems
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Health systems in transition Portugal 69
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3.6.2 External sources of funds
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3.6.3 Other sources of financing
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Health systems in transition Portugal70
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3.7 Payment mechanisms
3.7.1 Paying for health services
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Health systems in transition Portugal 71
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Health systems in transition Portugal80
Fig. 4.1Beds in acute hospitals per 100 000 population in Portugal and selected countries, 1990–2008
Source : WHO Regional Office for Europe, 2011.
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Table 4.1Number of beds in acute care, specialized hospitals, primary care centres and long-term care institutions in Portugal, per 100 000 population, 1995–2008 (selected years)
Hospital 1995 2000 2005 2006 2007 2008
Acute care hospitals 235.3 237.5 225.7 221.3 220.1 203.3
Specialized hospitals 52.4 42.6 32.4 30.5 28.0 24.7
Primary care centres 20.7 13.9 9.4 8.4 6.4 5.5
Long-term care network – – – – 1 788 2 870
Source : INE, 2009f.Note : Data are also available at http://www.pordata.pt/.
200
300
400
500
600
700
United KingdomSpain
PortugalItaly
France
2008200720062005200420032002200120001999199819971996199519941993199219911990
Health systems in transition Portugal 81
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Table 4.2Operating indicators in Portugal and selected countries, 1990–2007 (selected years)
1990 1995 2000 2005 2006 2007
Portugal ALOS: inpatient care, days 10.8 9.8 9.2 8.7 8.6 8.5
ALOS: acute care, days 8.4 7.9 7.7 7.1 6.9 6.8
Acute care occupancy rate, % of available beds 66.7 72.6 71.3 73.2 71.3 72.6
Day cases, % of total surgeries performed 0.3 6.4 17.6 18.9 23.3 –
Spain ALOS: inpatient care, days 12.2 10.0 9.0 8.5 8.3 8.2
ALOS: acute care, days 9.6 8.8 7.1 6.7 6.6 6.6
Acute care occupancy rate, % of available beds 73.5 76.4 77.2 79.1 78.2 78.2
Day cases, % of total surgeries performed – 16.8 31.4 32.2 33.4 –
France ALOS: inpatient care, days 15.1 14.1 13.2 13.3 13.0 13.0
ALOS: acute care, days 7.0 6.2 5.6 5.4 5.3 5.3
Acute care occupancy rate, % of available beds 77.3 76.0 75.4 73.5 73.7 73.9
Day cases, % of total surgeries performed – – – – – –
Italy ALOS: inpatient care, days 11.7 10.1 7.7 7.4 7.5 7.5
ALOS: acute care, days 9.5 8.4 7.0 6.7 6.7 6.7
Acute care occupancy rate, % of available beds 69.3 70.7 76.0 77.3 78.0 78.8
Day cases, % of total surgeries performed – 14.8 35.9 35.8 35.1 –
United Kingdom
ALOS: inpatient care, days – – 9.9 9.1 8.8 8.2
ALOS: acute care, days – – 8.2 7.9 7.6 7.2
Acute care occupancy rate, % of available beds – 83.4 83.9 83.5 83.4 –
Day cases, % of total surgeries performed 29.1 41.9 50.6 55.8 55.4 54.4
Source : OECD, 2010.
Health systems in transition Portugal82
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4.1.2 Capital stock and investments
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Health systems in transition Portugal 83
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Table 4.3PPPs in Portugal
Hospital de Loures II
Hospital de Cascais
Hospital de Braga
Hospital de V.F. Xira
Started 12 May 2006 13 May 2004 18 November 2004 20 April 2005
Preparation and previous evaluation
245 days 76 days 32 days 139 days
Approval and launch 66 days 40 days 30 days 88 days
Proposals 159 days 138 days 226 days 136 days
Evaluation of the proposals 404 daysa 509 days 436 days 690 days
Competitive bargaining – 171 days 380 days 132 daysa
Final bargaining – 315 days 200 daysa –
Beginning of the public–private partnership
– 8 October 2008 – –
Source : Court of Auditors, 2009.Note : a Measured on 16 October 2008.
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Health systems in transition Portugal84
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4.1.3 Medical equipment, devices and aids
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4.1.4 IT
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Health systems in transition Portugal 85
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4.2 Human resources
4.2.1 Trends in health care personnel
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Health systems in transition Portugal86
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Table 4.4Health care personnel, 1990–2008 (selected years)
1990 1995 2000 2005 2006 2007 2008
Doctors 28 016 29 353 32 498 36 183 36 924 37 904 38 932
Dentists 667 1 411 3 321 5 056 5 665 5 629 6 033
Orthodontists 375 341 293 384 374 374 374
Nurses 28 154 34 225 – 48 155 50 955 54 079 56 079
Pharmacists 5 438 – 8 056 9 494 10 091 10 117 10 729
Source : INE, 2009d. Note : Data are also available at http://www.pordata.pt/.
Fig. 4.2Number of physicians per 100 000 population in Portugal and selected countries, 1990 to latest available year
Source : WHO Regional Office for Europe, 2011.
0
100
200
300
400
500
United Kingdom
SpainPortugal
Italy
France
20092008200720062005200420032002200120001999199819971996199519941993199219911990
Health systems in transition Portugal 87
Fig. 4.3Number of nurses per 100 000 population in Portugal and selected countries, 1990 to latest available year
Source : WHO Regional Office for Europe, 2011.
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200
300
400
500
600
700
800
900
1 000
United Kingdom
Spain
Portugal
Italy
France
20092008200720062005200420032002200120001999199819971996199519941993199219911990
Health systems in transition Portugal88
Fig. 4.4Number of physicians and nurses per 100 000 population in the WHO European Region, 2009 or latest available year
Source : WHO Regional Office for Europe, 2011.Notes : p: physicians; n: nurses; CIS: Commonwealth of Independent States; CARK: Central Asian republics and Kazakhstan.
0 500 1 000 1 500 2 000Turkey (2008)
Belgium (2008)Albania
The former Yugoslav Republic of Macedonia (2007p, 2006n)Greece (2008)
TajikistanSerbia
Bosnia and HerzegovinaTurkmenistan
AndorraMontenegro
Poland (2008)Armenia
Cyprus (2008)San Marino (1990)
LatviaRomania (2008)
Kyrgyzstan (2007)Bulgaria (2008)Croatia (2008)
GeorgiaIsrael (2008n)
SpainEU members since 2004 or 2007 (2008)
Portugal (2008n)Malta
Hungary (2008)Slovakia (2007p, 2008n)
Estonia (2008)Slovenia (2008)
Italy (2008p)Republic of Moldova
CARKAzerbaijan
Eur-B+CLithuania (2008)
KazakhstanUkraine
WHO European Region (2008)EU (2008)
Czech Republic (2008)CIS
EU members before May 2004 (2008p, 2007n)France (2008p)
Eur-A (2008)Austria (2008n)United Kingdom
Russian Federation (2006)Uzbekistan
Luxembourg (2007p, 2006n)Netherlands (2007)
Germany (2008)Sweden (2006)
BelarusDenmark (2007)
Norway (2008)Finland (2008p, 2007n)
Ireland (2008p)Iceland (2008)
Switzerland (2008n)Monaco (1992p, 1995n)
1 480
300392
372
311272
342
358511
356
1 5361 547
1 244
400
370
1 400
1 429
1 5191 621
1 0681 083
1 051
284260
431267
468
344
377342
354
343
328
328315
381370
318
279
412
310
238
366
335
300309
304377
271
339
266467
360
354
238
221299
252287
346
207
238316
168
216
211
115
247
158
194
1 0941 040
806
859
953751
847838798
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615619
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468
465508
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287
438601
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Physicians Nurses
Health systems in transition Portugal 89
Fig. 4.5Number of dentists per 100 000 population in Portugal and selected countries, 1990 to latest available year
Source : WHO Regional Office for Europe, 2011.
4.2.2 Professional mobility of health workers
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Table 4.5Foreign physicians working for the NHS, 2004–2007
2004 2005 2006 2007
Total number of foreign doctors 2 113 2 123 1 990 1 903
Inpatient care 1 053 1 050 978 814
GPs 770 795 765 780
Public health 28 22 27 35
Other physicians 262 256 220 274
Source : Ministry of Health, 2010.
10
20
30
40
50
60
70
80
United Kingdom
Spain
Portugal
Italy
France
20092008200720062005200420032002200120001999199819971996199519941993199219911990
Health systems in transition Portugal90
4.2.3 Training of health care personnel
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Health systems in transition Portugal 91
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Fig. 4.6Number of pharmacists per 100 000 population in Portugal and selected countries, 1990 to latest available year
Source : WHO Regional Office for Europe, 2011.
40
50
60
70
80
90
100
110
120
130
United Kingdom
Spain
Portugal
Italy
France
20092008200720062005200420032002200120001999199819971996199519941993199219911990
Health systems in transition Portugal92
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4.2.4 Doctors’ career paths
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4.2.5 Other health staff career paths
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5. Provision of services
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5. Provisio
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Health systems in transition Portugal94
5.1 Public health
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Health systems in transition Portugal 95
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Fig. 5.1Outpatient contacts per person per year in the WHO European Region, 2009 or latest available year
Source : WHO Regional Office for Europe, 2011.Notes : CIS: Commonwealth of Independent States; CARK: Central Asian republics and Kazakhstan.
0 3 6 9 12United Kingdom
AlbaniaGeorgia
Cyprus (2008)Malta
Sweden (2006)Luxembourg (1998)
ArmeniaKyrgyzstan (2008)
TurkmenistanNorway (1991)
Denmark (2007)Bosnia and Herzegovina
TajikistanFinland
MontenegroIceland (2005)
Portugal (2008)Azerbaijan
RomaniaGreece (1982)
Bulgaria (1999)Latvia
EU members before May 2004 (2006)Netherlands
Eur-A (2007)The former Yugoslav Republic of Macedonia (2006)
Italy (1999)EU
IsraelRepublic of Moldova
CroatiaFrance (1996)Ireland (1988)
SloveniaKazakhstan
TurkeyPoland (2008)
LithuaniaCARK
AustriaBelgium
WHO European RegionEstonia
EU members since 2004 or 2007Germany (2008)
Eur-B+CSerbia
CISUzbekistan
Russian Federation (2006)Spain (2003)
UkraineSwitzerland (1992)
HungaryCzech Republic
SlovakiaBelarus 13.1
13.03 13.0
11.0 10.7
9.5 9.0 9.0
8.61 8.5
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7.1 7.09 7.0
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6.5 6.366.3
6.2 6.2
6.0 6.0 5.98
5.8 5.71
5.3 5.45.4 5.65.6
4.7 4.6
4.2
4.4 4.284.2
4.5
4.19 4.15
3.8 3.6
3.5 3.44
2.8 2.8
2.462.1 2.0
1.79 0.4
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5.4 Specialized ambulatory care/inpatient care
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5.4.2 Day care
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5.7 Rehabilitation/intermediate care
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Health systems in transition Portugal112
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5.8.1 Recent developments
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Table 5.1Number of beds in the long-term care network, 2007–2008
2007 2008
Number of long-term care beds (RNCCI) 1 788 2 870
Rehabilitation and medium-term 646 922
Long-term 684 1 325
Palliative care 55 93
Source : Ministry of Health, 2010.
Health systems in transition Portugal 115
5.9 Palliative care
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5.10 Mental health care
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5.11 Dental care
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5.12 Complementary and alternative medicine
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6. Principal health care reforms
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Health systems in transition Portugal120
6.1 Analysis of recent reforms
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Table 6.1Major policy measures, 2000–2009
Policy measures Objectives
PPPs for new hospitals (2002 onwards) Improve efficiency; improve value for money in public investment
National Health Plan (2004) Health gains (priorities being cardiovascular diseases, oncological diseases and HIV/AIDS)
Preparation of the National Health Plan (2011–2016) Focus on access, quality, healthy policy and citizenship
Update in co-payments of public health care services (several years)
Moderate the consumption of health care; promote the value of NHS-funded care in the eyes of the citizens
Closure of delivery rooms in several hospitals (2006) Increase clinical quality and safety; better organization of the hospital network
Merge hospitals management team (2003 onwards) Increase efficiency (take advantage of scale and scope economies)
Provide hospitals with entrepreneurial-like status (2003 onwards)
Implement purchaser–provider split; cost-containment by better management
Contracting (2005 onwards) Implement purchaser–provider split; pay by results; cost-containment
Reductions in public cost-sharing for pharmaceutical products, administrative price reductions and reductions of margins in distribution (2005 onwards)
Cost-containment
OTC products (both price and entry liberalization) (2005) Better access to care; lower prices by increased competition
Closure of several primary care emergency services (in some cases, closure is only during the night period) (2006)
Increase clinical quality and clinical safety; better organization of the emergency care network
Primary care reform – creation of USFs (2006 onwards) and ACES (2008)
Better access; greater satisfaction for professionals and citizens; more rational use of resources, namely regarding referral decisions
Price reduction in agreements with private providers (2006, effective 2007)
Containment of public spending
RNCCI created (2006 onwards) More effective coverage; better access to care; shorter length of stay in acute care hospitals; health gains due to more efficient treatment
Health systems in transition Portugal 121
6.1.1 Health promotion reforms
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6.1.2 Long-term care reforms
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Health systems in transition Portugal122
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6.1.3 Ambulatory care reforms
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6.1.4 Inpatient care reforms
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Health systems in transition Portugal124
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6.1.5 Pharmaceutical reforms
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Health systems in transition Portugal 125
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6.1.6 Regulatory reforms
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Health systems in transition Portugal126
6.2 Future developments
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7. Assessm
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7. Assessment of the health system
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Health systems in transition Portugal128
7.1 Stated objectives of the health system
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7.2 Financial protection and equity in financing
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7.3 User experience and equity of access to health care
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7.4 Health outcomes, health service outcomes and quality of care
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8. Conclusions
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9. Appendices
9.1 Prospective analysis of Portuguese health status
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9.1.1 Life expectancy
/LIH�H[SHFWDQF\�DW�ELUWK�PHDVXUHV�WKH�QXPEHU�RI�\HDUV�D�JLYHQ�SHUVRQ�ERUQ�LQ�D�JLYHQ�\HDU�FRXOG�H[SHFW�WR�OLYH��7KH�3RUWXJXHVH�SRSXODWLRQ¶V�OLIH�H[SHFWDQF\�KDV�LQFUHDVHG�PXFK�RYHU�WKH�ODVW�GHFDGHV��VHH�)LJ��������6LQFH�������OLIH�H[SHFWDQF\�DW�ELUWK�LQFUHDVHG�IURP������\HDUV�WR������LQ�������2(&'���������)RU�3RUWXJXHVH�ZRPHQ��OLIH�H[SHFWDQF\�LQ������ZDV�KLJKHU�WKDQ����\HDUV�ROG��
8VLQJ�WKLV�GDWD��ZH�FDQ�IRUHFDVW�ZKDW�FRXOG�KDSSHQ�RYHU�WKH�QH[W�GHFDGHV��DQG�FKHFN�ZKDW�ZRXOG�EH�WKH�3RUWXJXHVH�OLIH�H[SHFWDQF\�LI�QRWKLQJ�KDSSHQHG�WR�FKDQJH�WKH�WUHQG�OLQH��VHH�)LJ��������,Q�)LJ�������ZH�FDQ�VHH�WKDW�LI�QRWKLQJ�DIIHFWV�WKLV�WUHQG��D�3RUWXJXHVH�ERUQ�LQ������FDQ�H[SHFW�WR�OLYH������\HDUV��
2QH�FRXOG�DVN�ZKDW�FRXOG�EH�WKH�LPSDFW�RI�KHDOWK�SROLF\�RQ�WKH�RYHUDOO�KHDOWK�VWDWXV�RI�WKH�SRSXODWLRQ��7KH�1DWLRQDO�+HDOWK�3ODQ�DLPV�WR�LPSURYH�WKH�RYHUDOO�KHDOWK�VWDWXV�RI�WKH�SRSXODWLRQ��WKURXJK�FRPPRQ�KHDOWK�SROLF\�JXLGHOLQHV��WRJHWKHU�ZLWK�PRUH�VSHFLILF�WDUJHWV�LQ�WKH�KHDOWK�FDUH�V\VWHP��%HWZHHQ������DQG�������3RUWXJXHVH�KHDOWK�SROLF\�ZDV�JXLGHG�E\�WKH�1DWLRQDO�+HDOWK�3ODQ�����±������ZKLFK�ZDV�FRPPRQO\�SHUFHLYHG�DV�QRW�EHLQJ�YHU\�VXFFHVVIXO�LQ�DFFRPSOLVKLQJ�KHDOWK�JDLQV��:KDW�ZRXOG�EH�WKH�LPSDFW�RQ�OLIH�H[SHFWDQF\�RI�D�VXFFHVVIXO�1DWLRQDO�+HDOWK�3ODQ�����±����"�6XSSRVH�WKH�1DWLRQDO�+HDOWK�
9. Ap
pen
dices
Health systems in transition Portugal138
Fig. 9.1Life expectancy at birth, 1990–2003
Source : OECD, 2009.
Fig. 9.2Life expectancy at birth – forecast, 1990–2030
Source : OECD, 2009.
72
70
1990 1995
All Population trend Men Women
2000 2005
74
76
80
78
Years
75
1990 2000
Life expectancy at birth ForecastPessimistic scenario Optimistic scenario
2010 2020 2030
80
90
85
Years
Health systems in transition Portugal 139
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,Q�������D����\HDU�ROG�3RUWXJXHVH�PDQ�FRXOG�H[SHFW�WR�OLYH�IRU�DQRWKHU����\HDUV��%\�������WKLV�YDOXH�KDG�ULVHQ�WR������\HDUV��DQG�WKH�OLQHDU�IRUHFDVW�IRU������LQGLFDWHV�D�OLIH�H[SHFWDQF\�DW����RI������\HDUV��WKDW�LV��RQ�DYHUDJH��D����\HDU�ROG�PDQ�FRXOG�H[SHFW�WR�OLYH�XQWLO�KH�LV�����7KH�VDPH�W\SH�RI�HYROXWLRQ�RFFXUV�IRU����\HDU�ROG�ZRPHQ���,Q�6SDLQ��LQ�������D����\HDU�ROG�PDOH�FRXOG�H[SHFW�WR�OLYH�IRU�DQRWKHU������\HDUV��DQG�D�ZRPDQ¶V�OLIH�H[SHFWDQF\�DW����ZDV����\HDUV��
$�VXFFHVVIXO�1+6�FRXOG�OHDG�WR�KHDOWK�JDLQV�LQ�WHUPV�RI�OLIH�H[SHFWDQF\�DW�����,I�ZH�FDUU\�RXW�WKH�VDPH�WKRXJKW�H[SHULPHQW�DV�EHIRUH��WKHQ�D����LQFUHDVH�LQ�OLIH�H[SHFWDQF\�DW����E\������ZRXOG�OHDG�WR�DQ�DGGLWLRQDO�\HDU�LQ�OLIH�H[SHFWDQF\�DW�����IRU�ERWK�PHQ�DQG�ZRPHQ�
Fig. 9.3Life expectancy at age 65 – forecast, 1990–2030
Source : OECD, 2009.
15
1990 2000 2010 2020 2030
25
20
Years
Men Women Forecast (men) Forecast (women) Pessimistic scenario Optimistic scenario
Health systems in transition Portugal140
9.1.2 Potential years of life lost (PYLL)
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Fig. 9.4PYLL, 1990–2003
Source : OECD, 2009.
,Q�������WKH�QXPEHU�RI�3<//�SHU���������LQKDELWDQWV�VXPPHG�XS�WR�������:KHQ�ZH�FRPSDUH�PHQ�DQG�ZRPHQ��PHQ�VKRZ�D�PXFK�KLJKHU�SURSRUWLRQ�RI�3<//�������YHUVXV��������7KH�IRUHFDVW�SRLQWV�WR�D�ODUJH�GHFUHDVH�RYHU�WLPH��E\������±�SRSXODWLRQ��������PHQ��������ZRPHQ���������
:H�IRFXV�RQFH�DJDLQ�RQ�WKH�VFHQDULR�RI�IDFLQJ�KHDOWK�JDLQV�UHVXOWLQJ�IURP�D�GLUHFW�KHDOWK�SROLF\�LQWHUYHQWLRQ��WKH�1DWLRQDO�+HDOWK�3ODQ��,I�WKH�1DWLRQDO�+HDOWK�3ODQ�����±�����LV�DEOH�WR�DFKLHYH�ODUJH�KHDOWK�JDLQV�LQ�WKH�DYRLGDEOH�FDXVHV�RI�GHDWK��ZH�FDQ�HVWLPDWH�ZKDW�ZRXOG�EH�WKH�GHFUHDVH�LQ�WKH�3<//�E\�������)LJ�������
2 000
1990 1995 2000 2005
4 000
6 000
10 000
8 000
Population Forecast Men Women
Health systems in transition Portugal 141
Fig. 9.5PYLL – forecast, 1990–2030
Source : OECD, 2009.
7KH�3<//�SHU���������SRSXODWLRQ�FRXOG�DWWDLQ�D�PLQLPXP�RI������\HDUV�E\�����������\HDUV�OHVV�WKDQ�WKH�SUHGLFWHG�YDOXH��7KLV�VHHPV�WR�EH�D�UHDVRQDEOH�YDOXH��JLYHQ�WKDW�LQ������WKH�EHVW�(8���FRXQWU\��6ZHGHQ��SUHVHQWHG������3<//��7KH�OHYHO�IRU�ZRPHQ�FRXOG�EH�DV�ORZ�DV�������FRPSDUHG�WR�D�IRUHFDVW�RI������\HDUV���ZKHUHDV�IRU�PHQ�WKH�QXPEHU�ZRXOG�GHFUHDVH�WR�������YHUVXV�������6ZHGHQ¶V�OHYHO�LQ�������������
7KH�UDWLR�RI�3<//�SHU���������LQKDELWDQWV�LQFOXGHV�DOO�FDXVHV�RI�GHDWK��+RZHYHU��WKHUH�FRXOG�EH�D�ZD\�WR�WDFNOH�VSHFLILF�FDXVHV�RI�GHDWK��DQG�FRQFHQWUDWH�WKH�HIIRUWV�RQ�GHFUHDVLQJ�SUHPDWXUH�PRUWDOLW\��$V�DQ�H[DPSOH��KHDOWK�SROLF\�FRXOG�DLP�WR�LQFUHDVH�WKH�KHDOWK�JDLQV�LQ�VRPH�LQGLFDWRUV�WKDW�DUH�NQRZQ�WR�EH�VHQVLWLYH�WR�KHDOWK�FDUH�SURPRWLRQ��3ULPDU\�SUHYHQWLRQ�ZRXOG�KHOS�SUHYHQW�PDOLJQDQW�QHRSODVPV��OXQJ��WUDFKHD�DQG�EURQFKXV���LVFKDHPLF�KHDUW�GLVHDVH��FLUUKRVLV�DQG�URDG�WUDIILF�DFFLGHQWV��0DOLJQDQW�QHRSODVPV�RI�WKH�VNLQ�DUH�XVXDOO\�WDNHQ�WR�EH�DYRLGDEOH�E\�KHDOWK�FDUH�GHOLYHU\��7KH�HYROXWLRQ�RI�PDOLJQDQW�QHRSODVPV��OXQJ�DQG�VNLQ���LVFKDHPLF�KHDUW�GLVHDVH��FLUUKRVLV�DQG�URDG�WUDIILF�DFFLGHQWV�LV�VKRZQ�LQ�)LJ������
$V�ZH�FDQ�VHH��PXFK�KDV�EHHQ�DFKLHYHG�LQ�UHGXFLQJ�3<//�GXH�WR�ODQG�WUDQVSRUW�DFFLGHQWV��+RZHYHU��RWKHU�FDXVHV�RI�GHDWK�VHHP�WR�KDYH�VWDELOL]HG�RU�HYHQ�WR�EH�JURZLQJ��)LJ��������:KDW�FDQ�ZH�VD\�DERXW�WKH�QH[W�GHFDGHV"
0
1990 2000
Population Men Women Forecast Pessimistic scenario Optimistic scenario
2010 2020 2030
4 000
2 000
10 000
6 000
8 000
Health systems in transition Portugal142
Fig. 9.6PYLL – health care promotion, 1990–2003
Source : OECD, 2009.
Fig. 9.7PYLL – selected causes, forecast, 1990–2030
Source : OECD, 2009.
0
1990 1995
Lung cancer Skin cancer Ischaemic heart diseaseCirrhosis Land transport accidents
2000 2005
200
1 000
800
600
400
0
1990 2000
Lung cancer Skin cancer Ischaemic heart diseaseCirrhosis Forecast
20202010 2030
100
300
200
Health systems in transition Portugal 143
/XQJ�DQG�VNLQ�FDQFHU�UDLVH�FRQFHUQV�DV�FDXVHV�RI�GHDWK��JLYHQ�WKHLU�LQFUHDVLQJ�WUHQG��,I�WKH�1DWLRQDO�+HDOWK�3ODQ�����±�����LV�DEOH�WR�DFKLHYH����KHDOWK�JDLQV�LQ�WKHVH�WZR�FDXVHV��WKH�YDOXHV�FRXOG�EH�DV�ORZ�DV������OXQJ��LQVWHDG�RI������DQG�����VNLQ��LQVWHDG�RI�����3<//�SHU���������LQKDELWDQWV��)LJ�������
Fig. 9.8PYLL – scenarios, 1990–2030
Source : OECD, 2009.
$V�IRU�ODQG�WUDQVSRUW�DFFLGHQWV��IXUWKHU�SROLFLHV�DLPLQJ�WR�UHGXFH�WKLV�W\SH�RI�PRUWDOLW\�FRXOG�OHDG�WR�D�PLQLPXP�RI�����3<//�SHU���������LQKDELWDQWV�E\�������ZKLFK�UHSUHVHQWV�D�GHFUHDVH�RI���\HDUV�SHU���������LQKDELWDQWV�ZKHQ�FRPSDUHG�WR�WKH�VLPSOH�IRUHFDVW��)LJ�������
0
50
1990 2000
Lung cancer Skin cancer ForecastPessimistic scenario Optimistic scenario
2010 2020 2030
100
200
150
Health systems in transition Portugal144
Fig. 9.9PYLL – land transport accidents, 1990–2030
Source : OECD, 2009.
9.1.3 Standardized death rates
7KH�WKLUG�YDULDEOH�WR�ORRN�DW�LV�WKH�VWDQGDUGL]HG�GHDWK�UDWH��6'5���)LJ�������VKRZV�WKH�HYROXWLRQ�RI�WKLV�LQGLFDWRU�VLQFH�������7KH�GHFUHDVLQJ�WUHQG�LQ�WKH�6'5�LV�KLJKHU�LQ�WKH�PDOH�SRSXODWLRQ�
7KH�WRS�WKUHH�6'5�FDXVHV�RI�GHDWK�DUH�FHUHEURYDVFXODU�GLVHDVH��LVFKDHPLF�KHDUW�GLVHDVH�DQG�QHRSODVPV��)LJ�������VKRZV�WKH�IRUHFDVW�IRU�WKH�HYROXWLRQ�RI�WKHVH�YDULDEOHV��ZLWKRXW�DQ\�SROLF\�LQWHUYHQWLRQ��&HUHEURYDVFXODU�GLVHDVH�6'5�WHQGV�WR�GHFUHDVH�WR�WKH�OHYHO�RI�LVFKDHPLF�KHDUW�GLVHDVH�6'5��1HRSODVPV�6'5�VKRZ�DQ�DOPRVW�IODW�WUHQG��
)LJ�������VKRZV�WKH�HYROXWLRQ�DQG�SRVVLEOH�VFHQDULRV�RQ�WKH�6'5�RI�OXQJ�DQG�VNLQ�QHRSODVPV��,I�WKH�1DWLRQDO�+HDOWK�3ODQ�����±�����LV�DEOH�WR�KDYH�D�QHJDWLYH����LPSDFW�LQ�WKH�OXQJ�DQG�VNLQ�QHRSODVPV�6'5��WKHQ�E\�������ZH�FDQ�SUHGLFW�WKDW�WKH�VNLQ�QHRSODVP�6'5�FRXOG�EH�DV�ORZ�DV�����SHU���������SRSXODWLRQ��DQG�OXQJ�QHRSODVP�6'5�FRXOG�GHFUHDVH�WR�������YHUVXV�D�SUHGLFWHG�YDOXH�RI�������LQ�������)LQODQG�KDG�D�VLPLODU�6'5��������
200
1990 2000
Land transport accidents ForecastPessimistic scenario Optimistic scenario
20202010 2030
400
600
1 000
800
Health systems in transition Portugal 145
Fig. 9.10SDR – per 100 000 population, 1990–2003
Source : OECD, 2009.
Fig. 9.11SDR – selected causes, forecast, 1990–2030
Source : OECD, 2009.
400
1990 1995 2000 2005
600
800
1 200
1 000
Population Men Women Forecast
0
1990 2000
Cerebrovascular disease Ischaemic heart diseaseNeoplasms Forecast
20202010 2030
100
50
200
150
Health systems in transition Portugal146
Fig. 9.12SDR – scenarios, 1990–2030
Source : OECD, 2009.
9.2 References
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0
1990 2000 2010 2020 2030
10
30
20
Lung cancer Skin cancer ForecastPessimistic scenario Optimistic scenario
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Health systems in transition Portugal156
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9.7 About the authors
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The Health Systems in Transition profiles
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Key
All HiTs are available in English.When noted, they are also available in other languages:a Albanianb Bulgarianc Frenchd Georgiane Germanf Romaniang Russianh Spanishi Turkishj Estoniank Polishl Tajik
HiT country profiles published to date:
The
Euro
pean
Obs
erva
tory
on
Heal
th S
yste
ms a
nd P
olic
ies i
s a p
artn
ersh
ip b
etw
een
the
WHO
Reg
iona
l Offi
ce fo
r Eur
ope,
the
Gove
rnm
ents
of B
elgi
um, F
inla
nd, I
rela
nd, th
e Ne
ther
land
s, No
rway
, Slo
veni
a, S
pain
, Sw
eden
and
the
Vene
to R
egio
n of
Ital
y, th
e Eu
rope
an C
omm
issi
on, th
e Eu
rope
an In
vest
men
t Ban
k, th
e W
orld
Ban
k, U
NCAM
(Fre
nch
Natio
nal U
nion
of H
ealth
In
sura
nce
Fund
s), th
e Lo
ndon
Sch
ool o
f Eco
nom
ics a
nd P
oliti
cal S
cien
ce, a
nd th
e Lo
ndon
Sch
ool o
f Hyg
iene
& T
ropi
cal M
edic
ine.
HiTs
are
in-d
epth
pro
files
of h
ealth
syst
ems a
nd p
olic
ies,
prod
uced
usi
ng a
stan
dard
ized
app
roac
h th
at a
llow
s com
paris
on a
cros
s cou
ntrie
s. Th
ey p
rovi
de fa
cts,
figur
es an
d an
alys
is an
d hi
ghlig
ht re
form
initi
ativ
es in
pro
gres
s.
ISSN
18
17-6
127