Critical Governance

in Health in Portugal

5th International Conference

The financial crisis, welfare state challenges and new

forms of risk management

Store Restrup Herregaard

March 2th – 4th 2011

Presented by: Clara Michele Bruheim – cmbruheim@iscsp.utl.pt

Authors:

Maria Vitória Mourão – vitoria.mourao@gmail.com

Clara Michele Bruheim – cmbruheim@iscsp.utl.pt

Patrícia Campaniço – pcampanico@iscsp.utl.pt

Overview

• Background

• Objectives

▫ General Objectives

▫ Specific Objectives

• Methodology

• Results

• Conclusion

Background (1)

•Economic and Financial

Crisis: growth of the national

deficit and unemployment

•Ageing population, increased

life expectancy and more

chronic patients

•Technological innovations

Enhance of

population's needs in

using Health services

Responsibility to

provide efficient Health

care

Growth of Investment in

Health Care

Investment of 9.8% of

GDP

(Barros and Simões, 2007: XV)

Background (2)

• Optimization of invested

resources in Health

• Organization and

Coordination

Improvement of the

National Health System

Aim of the Study

Objectives (1)

• General Objectives

1)Clarify the planning and response mechanisms to take the most of

investment and increase the effectiveness of the National Health Service,

as well as the satisfaction of individuals needs and expectations;

2)Reveal the relationship between the public debate on costs and

quality of Health in Portugal and the formulation of new ways of

governance;

3)Assess the risk of different levels of health care for those who are

only users of the National Health Service and to holders of agreements

with sub-health systems or private insurance beneficiaries.

Objectives (2)

• Specific Objectives

1)Identify priority areas of health governance, given the current backdrop of

economic and financial crisis;

2)Build a framework of responses to major points of vulnerability of

Health Governance, namely: the financing of the National Health System;

the negotiations with suppliers of the Ministry of Health; the management of

human resources in Health, the role of the Citizen in strengthening the social

contract in Health Access to health care; the waiting lists for surgeries and

consultations; and the public-private partnerships.

Methodology

• Qualitative methodology

• Literature review and document analysis of secondary

statistical sources

• In-depth interviews to 9 privileged stakeholders in health,

chosen by snowball - 3 health professionals, 3 policy makers

and 3 experts in the field- using an interview guide, in the

months of January and February 2011

• Content analysis

Results (1) - Financing of the National Health Service in a crisis context

Current health expenditure in Portugal is not excessive compared in absolute

terms with other OECD countries

To optimize investment and improve the efficiency of the system

Increase tax revenue from the profits of large economic and financial groups;

Reduce waste and inefficiencies;

Strengthen the network of primary and preventive care

Optimize technological resources

Electronic prescription of medicines and diagnostic methods, electronic health record

Prescription by International Denomination of substances

Increase the use of generics

Long-term negotiations with the suppliers of the Ministry of Health

Results (2) - Human Resources Management

Strategic management of human resources

Definition of the ratio of professionals per inhabitant

Require full-time schedules and an exclusive dedication of

professionals

Give more stability to professionals and dignify careers

Assign roles to nurses to release doctors

Have an effective top governance, independent of political interests,

which articulate the action of the various organisms

Recruitment to positions according to skills and professional profiles

and a good monitoring of professionals’ activities.

Results (3) - The reinforcement of the Health social contract: the role of the citizen

Health

System

Citizen

Active

participation of

the Citizen

Civil Society

Information and

Communication

Technologies

Health Literacy

Promotion of

Prevention and

Education on Health

Results (4) - Access to health care: the right to health as a fundamental right

• Barriers to access health care

• Access to health care

▫ Portuguese Constitution - the right of access to health care, through the National Health

Service

▫ The private sector (profit and nonprofit) - a complementary role in health care

▫ The non-profit sector or third sector - important role in access to healthcare for vulnerable

populations - importance to define and regulate the role of the social sector

• Waiting Lists

▫ Improved response to waiting lists

▫ Promotion of publication of the waiting times

▫ Diagnosis and evaluation of waiting lists

▫ Redefining the roles of health professionals

▫ Better management and human resources planning

▫ Strengthening Primary health care

Results (5) - Public-private partnerships with the Profitable sector

• Adverse opinions are based:

▫ in the absence of public interest of these partnerships

▫ In confusion between public and private money

▫ In the need to have an evaluation and technical assessment to

those partnerships that don't exist

• The risk of arising of two levels of performance, one to the users of

the National Health Service and other to holders of agreements with

sub-health systems or private insurance beneficiaries

Conclusions (1)

Crisis situation and the risks

the need for decisions

To transform the unforeseen consequences of decisions

additional mechanisms introduction of cost containment

• The Funding of National Health Service: public debate of the state budget and the reduction of waste

and inefficiencies;

• The medicine policies: negotiations with suppliers over the long term; ready-payment of goods;

prescription taking into account the user’s clinical and financial situation; and promoting generics use;

• The Health’s human resources: human resources planning and management and training; dignity of

medical careers; status of exclusivity and increased availability, and people’s nomination to positions

based on principles of competency and job profiles;

Conclusions (2)

• The Health social contract: strengthening the contract, and the citizen’s role;

• The access to health care: the social sector’s role and strengthening primary care;

• The Waiting lists for consultations and surgeries: publishing of the maximum terms for

consultations and surgery; diagnosis, monitoring and evaluation of waiting lists; and

strengthening primary care;

• And the public-private partnerships with the profitable sector: partnerships with a clear

public interest; and regulation, inspection and evaluation of partnerships.

The debate about costs and quality of health in Portugal generates new forms of governance

Risk as a social construction that legitimizes certain governmental practices

Thank you for your attention

For more information,Please Contact:

Michele BruheimResearch Fellow

Centre for Public Admnistration and Public Policies and Public Policy (CAPP)

Institute of Social and Political Sciences (ISCSP)Technical University of Lisbon (UTL)

Rua Almerindo Lessa 1300-663 Lisboa Tel: [+351] 21 361 94 30 Ext.3223

Fax:[+351] 21  361  94  42 Mob.: [+351] 91 825 85 54

E-mail:cmbruheim@iscsp.utl.pt  

 Patrícia Campaniço

Research FellowCentre for Public Admnistration and Public Policies and Public Policy

(CAPP)Institute of Social and Political Sciences (ISCSP)

Technical University of Lisbon (UTL) Rua Almerindo Lessa 1300-663 Lisboa

Tel: [+351] 21 361 94 30 Ext.3224Fax:[+351] 21 361 94 42 Mob.: [+351] 96 44 24 86

Skype: patricia.campanicoE-mail:pcampanico@iscsp.utl.pt