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Health systems in transition
Portugal
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Table 3.3
Funding mix for the health system (%), 2000–2015 (selected years)
2000
2005
2010
2011
2012
2013
2014
2015
a
Public funding
70.5
71.3
69.8
67.7
65.6
66.9
66.2
66.0
Private funding
29.5
28.7
30.2
32.2
34.4
33.1
33.8
34.0
Not-for-profit
institutions
serving families
0.2
0.2
0.2
0.2
0.1
0.1
0.1
0.1
VHI
12.3
16.0
15.6
15.6
15.3
15.8
16.0
16.1
OOP payments
84.6
81.1
81.2
81.4
81.8
81.5
81.5
81.4
Other private funding
2.8
2.7
2.9
2.8
2.7
2.5
2.4
2.4
Source
: Authors, based on the Satellite Account for Health (INE, 2016f).
Note
:
a
Provisional data.
Box 3.1
Assessing allocative efficiency
Financial resources directed towards health care have reached a high level relative to the country’s
wealth. The share of GDP devoted to health expenditure in recent years (Table 3.1) puts Portugal in
line with the level of health spending within the EU. Since the mid-1990s, Portugal has witnessed
a steady and fast growth in public expenditure on health, with private expenditure remaining
relatively constant (i.e. growing in line with GDP growth). That trend was reversed in 2010, with
a decrease in public spending and an increase in private expenditure.
There has been a move away from historically based allocation of funds towards an approach
close to needs-based allocation. This is the trend in primary care, particularly since 2012. On the
other hand, hospital care is moving towards a contract-based approach, where an explicit target
for “production” and the corresponding payment are spelt out. As health care activity increasingly
follows the health care needs of the population the system moves closer to a needs-based approach.
The fact that contract-based approaches were used in hospitals before primary care is explained
by the use of DRGs and the introduction of private management in public hospitals in the 1990s.
Hence, NHS hospital management moved away from historically based allocation of funds towards
contracts (
contratos-programa
) signed between the NHS (as funder) and the hospitals. Contract-
based approaches were introduced in primary care only later and gradually.
Human resources in Portugal have been characterized by a higher emphasis than most other
countries on specialist hospital care, coupled with a relative scarcity of physicians and low
productivity. More recent years have shown a movement towards correction of these imbalances
(see Section 4.2.2). In particular, an increase in the ratio of GPs to specialists in hospitals, as well
as an increase in the ratio of nurses to doctors, at national level, is observed. Some of these changes
have been the result of government policy regarding vacancies for postgraduate medical training
in NHS institutions. However, the shortage of physicians became more evident with the early
retirement of many physicians, fostered by the civil servants’ retirement plan reform.