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Health systems in transition
Portugal
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Box 3.3
Assessing progressivity and equity of health financing
The Portuguese NHS is financed through general taxation, but the discussion on whether the fiscal
system is regressive or progressive is complex.
Regarding user charges, the unemployed, pregnant women, blood donors, donors of live cells and
tissues, firemen, people aged 18 years or under, and those belonging to certain patient groups
are exempted from user charges throughout the NHS. Also in the pharmaceutical sector, new
co-payment tables were created targeting the most vulnerable groups of the population.
More complex issues in regressivity are related to access to specific health care that the NHS
does not provide, particularly dental care. In this case, patients are forced to use private providers,
with or without reimbursement, total or partial, depending on social or voluntary health insurance
schemes. The same happens with private outpatient consultations, imaging or laboratory tests,
whose costs are incurred by patients on the conditions above mentioned.
The burden of regressivity in health funding is not likely to have been reduced in recent years,
since the use of private providers has been growing while the public sector has maintained the level
of service provision. That is, by using private providers regressivity increases because it allows
more fiscal deductions that benefit the richest.
3.3.3 Pooling and allocation of funds
The Ministry of Finance sets the NHS budget annually, based on historical
spending and plans put forward by the Ministry of Health, within an overall
framework of political priority setting across the different sectors. Capital and
current expenditure are separated, with the Ministry of Health retaining control
for all capital expenditure. The ACSS, which is the department responsible
for financial management within the Ministry of Health, prepares estimates
detailing the resources required to support planned activities. The estimate
of total expenditure for the current year is adjusted by the expected increase
in the level of consumption and salary levels. The Ministry of Finance, based
on macroeconomic considerations, ultimately determines the global budget
for health.
The Ministry of Health receives a global budget for the NHS, which is then
allocated to the many institutions within the NHS (hospitals; health regions,
which then allocate funds to primary care centres; and special programmes).
The Ministry of Health allocates a budget to each RHA for the provision
of health care to a geographically defined population. In practice, however,
RHA autonomy over the way in which the budget is spent has been limited
to primary care, because hospital budgets are still defined and allocated at
the central level.