Critical Governance in Health in Portugal

1. 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 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

2. Overview • Background • Objectives • General Objectives • Specific Objectives • Methodology • Results • Conclusion

3. 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)

4. Background (2) • Optimization of invested resources in Health • Organization and Coordination Improvement of the National Health System Aim of the Study

5. Objectives (1) • General Objectives • 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; • Reveal the relationship between the public debate on costs and quality of Health in Portugal and the formulation of new ways of governance; • 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.

6. Objectives (2) • Specific Objectives • 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.

7. 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

8. Results (1) - Financing ofthe 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 • Optimizetechnological 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

9. 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.

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

11. 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

12. 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

13. 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;

14. 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

15. Thank you for your attention For more information, Please Contact: Michele Bruheim 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.3223 Fax:[+351] 21  361  94  42 Mob.: [+351] 91 825 85 54E-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 86Skype: patricia.campanicoE-mail:pcampanico@iscsp.utl.pt