Health Systems in Transition

Health systems in transition

Portugal

experience of the English NHS project finance initiative, and the P-PP model

includes clinical services in the package in addition to ancillary services, for the

first batch of hospital P-PPs. Legal provisions have been undertaken (Decree-

Law No. 185/2002, of 20 August 2002) to create an adequate framework for the

further implementation of actual partnerships. Although the initial intention

was to extend the model to almost all types of health facilities, priority has

been given to hospitals. Between 2003 and 2006, four hospital projects were

launched under P-PPs: Cascais (opened in 2009), Braga (2011), Loures (2012)

and Vila Franca de Xira (2013). The Task Force for Partnerships in Health,

with specialized human resources and together with external consultants, was

responsible for these P-PPs within the Ministry of Health.

Currently, the Portuguese experience in P-PP in the health sector includes

the hospitals in Cascais, Braga, Loures and Vila Franca de Xira. These four

hospitals included clinical management in the P-PP. Previously, the southern

rehabilitation centre (CRSul) at São Brás de Alportel (Algarve), operating since

2007, was also under a P-PP model. In 2009, a specialized team analysed the

performance of the CRSul, comparing it to other rehabilitation centres in the

country and results indicated that it was too early to draw conclusions about

the added value of the P-PP model in terms of clinical management (see Barros,

2010: 519–560). In 2013, CRSul was integrated in the RHA of Algarve.

The progress of the four most recent P-PPs was evaluated by the Court of

Auditors, whose report concluded that the costs with P-PPs in the health sector

were underestimated by the Ministry of Finance: instead of a €4.143 million

expenditure, the Court estimated a €10.445 million expenditure until 2042

(Court of Auditors, 2013). More recently (August 2015), the Court of Auditors

evaluated the Loures Hospital and concluded that there was no evidence

supporting a greater efficiency of the private management model (Court of

Auditors, 2015). Also, a report from the HRA evaluated the four P-PP hospitals

from four dimensions – relative efficiency, efficacy, quality and regulation

costs – and concluded that it was not possible to draw lessons regarding the

advantage or disadvantage of the P-PP model (ERS, 2016b).

The process of each P-PP is complex and lengthy, involving preparation and

previous evaluation, the approval and launch of the contest, the proposals and the

evaluation of these proposals, which is followed by a competitive bargaining and

finally the final bargain with the winner. Each step of the process takes months, and

sometimes the process has to start from scratch all over again, due to bureaucratic

problems. At the time of writing, no P-PPs have been agreed for the planned hospitals,

but the decision on the model that will be adopted by the new

Hospital de Todos os

Santos

(Lisbon) may reopen the debate on the P-PPs in the health sector in Portugal.