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Health systems in transition
Portugal
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(opting out); the integration of health care, with the possibility of creating
health care units that would assemble hospitals and primary care units within
a single region.
The health care delivery system in Portugal consists of a network of public
and private health care providers; each of them is connected to the Ministry of
Health and to the patients in its own way. The key relationships are shown in
Fig. 2.1, with the Ministry of Health coordinating all health care provision and
the financing of public health care delivery.
Box 2.1
Historical background
The current Portuguese National Health Service (NHS) was established in 1979 (for earlier
developments, see Barros et al. (2011)). Its creation was in line with the principle of every citizen’s
right to health, embodied in the new democratic constitution (1976). Existing district and central
hospitals as well as other health facilities, previously operated by the social welfare system
and religious charities, were brought together under “
a universal, comprehensive and free-of-
charge National Health Service
”. The 1979 law establishing the NHS laid down the principles of
centralized control but decentralized management (see Barros et al., 2011).
A number of changes were introduced to the NHS since its creation, namely the introduction of
user charges. However, to assure all citizens would have access to health care regardless of their
economic and social background, exemptions were also created at the same time (see Barros et al.,
2011). Despite the development of a publicly financed and provided health system, some features
of the previous system remain unchanged, namely the health subsystems, which continue to cover
a variety of public (civil servants) and private (e.g. banking and insurance companies, postal
service, etc.) employees (see section 2.1.6). Although the NHS incorporated most of the health
facilities operating in Portugal, private provision has always been available, namely in clinics,
laboratory tests, imaging, renal dialysis, rehabilitation and pharmaceutical products.
Following the creation of the NHS, Portuguese health policy went through several periods, from
the development of an alternative to the public service (early 1980s), to the promotion of market
mechanisms (mid-1990s), and the introduction of a number of policies that drifted away from the
market-driven health care provision (late 1990s). By the beginning of the twenty-first century, the
NHS became a mixed system, based on the interaction between the public and the private sectors,
integrating primary, secondary and long-term care. Reforms were enacted aimed to combine the
universal coverage provided by the NHS and the promotion of efficiency.
By 2011, the Economic and Financial Adjustment Programme brought a number of cost
containment measures, including the health sector. The aim was to cut costs and increase the
system’s efficiency. Overall, most of the adjustment in spending in the health sector resulted
from price effects, few from quantity cuts, and only a small part was due to shift of financial
responsibility from the government to citizens. That was achieved through a reduction in the
level of salaries paid to health workers, cuts in public pharmaceutical expenditure, and price
review regarding private institutions that have contracted with the NHS. Medical practice was
also targeted with the introduction of clinical guidelines.