Summary
A stronger pressure on health and social care systems deriving from demo-graphic, social, economic and epidemiologic changes is a general tendency governments are facing worldwide and Portugal is no exception. In light of firm budget constraints and scarcity of resources the variety of promising solutions seems limited.
A number of reasons, from inefficacy and inefficiency of the system, through in-creasing operational costs to a low level of accessibility and a lack of satisfaction of both patients and health professionals, have led policymakers to reconsider the con-struct of healthcare.
The objective of this paper is to present the advances in a recent reform chosen by the policymakers in Portugal to rebuild the primary health care, guaranteeing availability, service quality and satisfaction for patients, motivation for professionals and sustainability for the system. If accomplished successfully, the reform may result in developments in terms of organizational aspects of care management and, in me-dium and long term, in improvement of health status and, consequently in enhancement of the quality of life of the society. It is, therefore, an economic issue, and its relevance should be acknowledged and continuously supported by the author-ities.
Potentially, some achievements and practices here presented could be traced and acquainted by other health systems in transition, bearing in mind that this is a highly country-specific matter and they should be eventually adjusted to the uni-queness of the proper system, economic conditions and cycle, and culture.
Keywords: primary health care, health center, patient, reform, system, Portugal 1. Introduction
It is generally acknowledged that for a patient primary care is the first entry point into the health system [14] and plays the key role as the system’s spokesman. It explains why it should not be treated as a separated dimension but defined in relation to other constituents of the health system.
practic-al, scientifically sound, and socially acceptable methods and technology that are universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their develop-ment in a spirit of self-reliance and self-determination [21]. Over three decades later, one can argue until which point policymakers have managed to put this vision into practice. The fact is, the primary health care in Portugal still requires a better planning, coordination and cooperation [8].
Demographic challenges of last decades, with an increase of life expectancy and a change in the population structure, have brought chronic diseases in magnitude never observed before and have shifted healthcare provision into long-term care requiring integration and coordination between services and providers.
Nowadays, an access to care in Portugal is limited by a number of factors such as long waiting lists, lack of certain health professionals categories, geographical distance to the nearest and most appropriate health provider and prices of health services. Moreover, recent economic, financial and social crisis, experienced by a major number of world economies, reached also Portugal, and has resulted in a decreased purchasing power constituting a significant factor influencing an access to care. These aspects often preclude developing the first contact with health care into an ongoing process of treatment among various health care institutions, what leaves a significant part of the population underserved. In 2007, the most important reason for having perceived an unmet medi-cal need was because it was too expensive and a person could not afford it and the probability of this happening was more than twice as high as compared with the EU-25 [10].
As insufficient and unsuitable health care that may lead in medium and long term to a deteri-oration of the population health status and, consequently, to a decline of the quality of life, the most urgent and crucial area for an action turns to be primary care. Its aim is yet to provide a patient with a broad spectrum of care, guaranteeing appropriate, accessible and affordable services. It is vital to act in order to ensure quality, in its several dimensions.
In recent years, the Portuguese have been experiencing the unique in history change in prima-ry care. Primaprima-ry care is the first pillar, often the first and unique, due to financial limitations, contact point with medical care. The reconstruction of the system is in country conditions a truly unique event. For the first time, the theoretical assumptions of patient-driven care have been in practice taken into account initializing a thoughtful reorganization of the model, actors and respon-sibilities.
2. The Portuguese model of primary health care The primary health care pathway
The Portuguese care system derived from a worrying scenario of geographical asymmetries, lack of state intervention and low level of professionalization accompanied by very frail health status indicators in the society, especially in terms of infant and children mortality and life expec-tancy. In the 1970’s infant mortality rate was 55,5‰ and average life expectancy 66,7 years [15], and these indicators were low as for the European reality.
Given its current social and economic development, Portugal has a relatively short history of primary care system, at least as such. Before its official foundation, care was, however, provided for concrete professional groups by initiatives of health professionals through establishments named “caixas de previdência”. Primary health care system was created in 1979 and organized
within a network of health centers. Although having in disposal low quality equipment and lacking of staff, those called with time “first generation” centers managed to achieve relevant success in terms of health prevention, having combated the negative trends in mortality and longevity. Portugal went through remarkable social changes. Between the 1970’s and 1980’s infant mortality rate radically dropped by 52,2 percentile points, reaching 3,3 ‰. The average life expectancy increased within this decade from 66,7 years to 79,3 years (76,2 years for men e 82,4 years for women) [15]1. Practically, during the 20th century life expectancy at birth in Portugal doubled [4].
Later on, “first-generation” health centers and “caixas de previdência” were united into “second-generation” health centers. It is considered that, by an exalted bureaucracy and unproduc-tive patterns of management, they provoked inefficacy and inefficiency initiating an accumulaunproduc-tive spiral of costs which consequences the system and the society are feeling up to now. The retros-pective financing basing the entity budget on previous year’s expenses corrected on the inflation rate led to misuses in the supply management. Moreover, there were no attempts to motivate human resources of the area: contracted salaries were constant, budget independent on a number of patients received and performance never taken into account.
In search for innovative solutions arose Experimental Remunerative Regimes (Regimes Re-muneratórios Experimentais): groups of entrepreneurial professionals convinced about collaboration and communication as a premise of quality of care. In contrary to the general rule their salary was based on performance and capitation: factors improving significantly employees’ motivation. In the future, this experience became fundamental for setting up the new health care model and Family Health Units in particular. The project was soon followed by creating “third-generation” health centers.
Given a rigid and inflexible approach to care institutions management, inefficiency in manag-ing resources and additional pressure on health expenditures with tight budget constraints [11] it turned unquestionable that the current system of primary care was representing inadequacies that had to be reorganized in order to better tackle the health challenges of the nearest future. This brought up inevitable thoughts on how to combat the system’s weaknesses and failures and offer citizens a system that is efficient, effective and fair in provision of health care. Subsequent go-verning parties have recognized, in fact, the importance and urgency of the health care reform; many projects, however, have never been launched.
Health care reform is, in fact, an economic reform. Poorer health condition and a shorter lifes-pan limit the economic productivity of the active population whose employment is crucial to guarantee social protection of the elderly. A lower crude birth rate is already a meaningful threat for the future social protection; therefore the current focus should direct into prevention of an absence at work due to health condition. Prevalence of chronic diseases, such as stroke or hyper-tension, continue substantial in Portugal [17]. They are important factors leading to morbidity, disability and dependency, what imposes high costs to the patient, family (both financial and psychological) and, already overburdened, health and social systems. The recession of last years and the negative economic growth make it challenging to authorities to combat a significant 1 In terms of life expectancy at birth some further improvement is possible. In what concerns infant mortality, there is still
some, but not great, scope for further gains as the current levels are already very low. In 2007, infant mortality rate was 3.4 deaths per thousand live births. To sum up, recent trends in mortality indicate that further declines in mortality can be expected, particularly at advanced ages. Longevity improvements are also expected from the decline in "avoidable" mortality at adults ages, particularly associated with the reduction of risk of death from external causes [6].
discrepancy between current health care provision and actual population needs. The question to be made is why Portugal total expenditure on health as the GDP share places the country at the top of list while it reports, in parallel, relatively faint results in terms of population health.
The reform aims at creating structures that will be able to maximize and rationalize existing, available resources, what would be a step to face ever growing costs. Concern on the quality brings the need to consider long term results, along a patient’s path among the care system, with the continuity of care and care transitions, in order to avoid errors and guarantee a considerable level of satisfaction. The proposal promotes innovative new ways to provide a better coordinated care to better meet the needs of patients and families, especially those with chronic conditions. Behind lies a willingness to expand health coverage to the maximum number of citizens, to ensure its quality and to make it affordable.
Core components of the new model
An assumption of a reform is a deep willingness to change; this is, however, in most cases, re-alized as an imposed strategy while the main actor turns to be a passive spectator of directives implementation. For the success of a care reform, it needs to be prepared with a compliance of national guidelines and with participation of the society. Finally, while the need of a care reform is clear, it is basically not quite clear how to organize it and implement it.
The progressing transformation of the primary health care is considered unique in history the Portuguese health care. For the first time, having pondered failures of previous attempts to the system restructuring, a bottom-up method was applied. The starting point was a general dissatis-faction among the system’s users and not the legislative framework compelled by the central authorities.
The mission that the model follows implies existence of a defined group of professionals who provide a defined pack of health services to a defined group of population, supported by a well-designed and adequate information and communication systems.
Primary Care Trusts (Agrupamentos de Centros de Saúde – ACES) are public services consti-tuted by a number of functional units, with administrative autonomy. They may contain a range of Family Health Units, Community Care Units, Personalized Health Care Units, Shared Assistance Resources Units and traditional health centers together with the Public Health Unit, the Manage-ment Support Unit and a Clinical Council respective for every ACES.
Figure 1: The new model of the Portuguese primary health care
Source: Relatório do Grupo Consultivo para a Reforma dos Cuidados de Saúde Primários. Acontecimento extraordinário. SNS – proximidade com qualidade. 2009. p. 11–40. Re-trieved from http://www.portaldasaude.pt/portal/conteudos/a+saude+em+portugal/ noticias/arquivo/2009/3/sns+proximidade.htm, accessed on September 14, 2010.
The crucial role in the system plays a Family Health Unit (Unidade de Saúde Familiar – USF), a nuclear group of health professionals who accompany a given case; typically a family doctor, family nurse and an officer who deals with administrative part of the process, although they may use common resources of the ACES, depending on their availability. USF are consi-dered, until some point, an extension of competencies and responsibilities of health centers [9], nevertheless, one needs to point out a crucial distinction between how they concern the quality of service provided, work principles and decision making process. USF characterize functional and technical autonomy and, by assigning a quality compromise with ACES, they oblige themselves to satisfy a number of pre-defined indicators, currently divided into four groups: accessibility, assis-tance, efficiency and patient satisfaction, with measurable goals. Currently, two types of USF, models A and B can be distinguished depending on the quality of service provided measured by a set of indicators and a level of professionals’ involvement. When meeting the defined quality criteria, USF are entitled to financial incentives to be applied into the scope of their activity: formation, improvement of facilities and professional development of the staff.
Community Care Units (Unidades de Cuidados na Comunidade – UCC) are strategic units, with a plan preceded by health and social diagnosis of a given community and consisting of programmes to be implemented continuously in order to solve the problems defined. They provide health and social services within a domiciliary and communitarian scope. These entities arose and were considered essential to be incorporated into the new model since traditionally health centers in Portugal used to be involved also in some community activities. The vital difference between
USF and UCC is the emphasis: while for USF it is a patient and a family, the aim of UCC services provision is community as a whole.
Personalized Health Care Units (Unidades de Cuidados de Saúde Personalizados – UCSP) are transition models between health centers and USF. Offering the same type of services and re-quested to obtain a service quality deemed minimum though indispensable in order to guarantee an equal standard of services, they are not entitled to financial incentives. Efforts are being made to promote advantages of the new model and their transformation into USF, what implies improve-ment of some organizational practices.
Shared Assistance Resources Units (Unidades de Recursos Assistenciais Partilhados – URAP) are entities composed of a number of different health professionals’ categories and respon-sible for common resources allocation depending on the request.
Public Health Units (Unidades de Saúde Pública – USP) are transversal bodies, with specific tasks encompassing prevention and resolution of problems that affect considerable groups of a given population. While each of other entities focuses on a limited geographic area, USP develop the activity in the whole territory of the ACES.
Management Support Units (Unidade de Apoio à Gestão – UAG) link administrative profes-sionals who deal with bureaucratic and operational issues.
Finally, Clinical Council (Direcção Clínica) is a technical organ of clinical governance, com-posed by professionals with background in health, who offer support in decisions for the Executive Director.
3. Advances in the primary health care reform
Currently, we are facing a moment when all entities cited by the reform have actually been appointed and are active actors in the health arena; with an exception of USF created from 2006 on, all of the others have only been brought to life very recently, in 2009.
The number of Family Health Units has been significantly increasing, from 15 to 57 in 2008, to reach 253 until September 2010 (table 1).
Table 1: Chosen characteristics of Family Health Units
USF Potential users Coverage gain Professionals Doctors Nurses
Applications 340 4123822 527630 6592 2335 3368
Active USF 253 3171921 386696 5044 1795 1813
Source: adapted from: http://www.mcsp.min-saude.pt/engine.php?cat=32, accessed on September 10, 2010.
Hospital emergency facilities are a solution chosen by patients who, independently on reasons, cannot obtain a medical appointment within the primary or secondary health care. In Portugal this is a particular problem and a number of non-urgent cases in an emergency department is elevated [9]. It is estimated that around one fourth of patients in hospital emergency department do not need immediate medical care [5]. To a patient of a Family Health Unit a guarantee to be attended, even
in case of his family doctor’s absence, has been provided: such does not take place in case of health centers. In many cases, extended working hours are a premise of health accessibility.
The new care model is expected to decrease wastage and offer better expenses control putting an end on a continuous cost increase of last years and bring savings to the system. These may be further destined to finance incentives offered to USF for satisfying quality indicators. The number of USF that reached quality standards and were entitled to institutional incentives in the North Region of Portugal arose from 40% to 64% between 2008 and 2009 [2] [3], what suggests that there is some knowledge sharing within the system.
Basically, the retrospective financing model is being maintained, however, strategic planning and performance monitoring together with efficient scarce resources managing give encouraging prospects for the future. When all entities involved sign the quality compromise with respective ACES, what is expected to happen until the end of 2010, the next step will be to move forward into the prospective financing, in the function of activity. That is a natural way systems develop: few current health care schemes finance the expenditures simply per capita since, depending on age and other characteristics, patients tend to have different health paths and bring different level of expenditure into the system.
Studies show that patient evaluation is a reliable instrument for quality improvement [20]. The results of a questionnaire conducted in 2009 among USF (at the time being the only ones active health care model entities) users and professionals clearly indicate that 89,4% of patients are satisfied with health professionals and 88,9% with facilities. 93,7% of the users would strongly recommend their USF to a friend while 6,3% would not; a negative answer to a similar question relative to the health centers users in 2003/2004 was given by 38,9% respondents. Health profes-sionals considered themselves much more motivated than in the previous system [24]. This might then be a reason to think that the reform is going in the right direction. Nevertheless, the evidence on the model behavior in a real setting relates to a short period of time and, as a whole, is being collected, for the first time, now.
An interesting perspective is a change in an attitude towards resources observed in Family Health Units. Behavior modification is hard to reach; nevertheless, health professionals, motivated by incentives that stay behind established quality indicators, have managed to deal much better with organizational aspects of care. An USF may reach and surpass, in a group of indicators, all of them, but needs to satisfy those of economic efficiency in order to be entitled to incentives. Until the new health care model implementation, Portugal had remained one of the few EU countries with health professionals’ performance not taken into consideration in the remuneration. Within the USF Model B, professionals may append the base salary through personal supplements and performance amends.
The incorrect health human resources policy of the 1980’s has resulted in short supplies of certain categories. The situation exacerbates as active professionals naturally get retired. This is seen mainly in case of general practitioners. Furthermore, judged by professionals as low and non-motivating salaries in the public sector drive them to multiple employment and the private health market seems a promising perspective [12] [13]. This additionally limits human resources availa-ble for the public health sector. Availaavaila-ble professionals tend to be focused in the main urban areas, Lisbon, Coimbra and Porto, leaving the significant part of the country without necessary services [7]. The geographical distribution of health services is very much uneven [16] [19].
a reform of a public system financed internally from public funds. Policy makers should then become engaged in this discussion with the whole society as participative nature of citizens can bring better results, fitting exactly their needs. Moreover, health is a common issue which affects, sooner or later, everyone. Patients within each ACES may form a community council composed of city halls assemblypersons chosen in elections, but the interest in limited. In Portugal, patient empowerment is still considerably low, although there are sparkles of change following a general [1] [22] trend of becoming more interested in managing the own health. As Family Health Units users appear to be more satisfied with care received, other patients start actively searching solu-tions within the system that would also provide them with a higher level of satisfaction. It is crucial to maintain this trend of a positive word-of-mouth.
4. Future challenges
Currently, a mixed model of primary health care points out a parallel existence of traditional care providers together with entities constituting a core of the new system. Until the end of 2010, however, it is expected that health centers sign with a respective ACES a contract obliging to reach base quality indicators among those applied for USF and UCSP. This is a way to guarantee equity of services within the system and avoid differentiating the system users.
The model as a whole was established only until 2010: the last appointed were proper Pri-mary Care Trusts. Since strategic decisions are taken on a basis of current situation, this was considered the best timing. Obviously, in a phase of transition not everything works as planned, though, unnecessary delays in the reform implementation can cause some mistrust, diminish motivation and lead to subsequent deviations.
Factors that may impede a favorable evolution of the model are an excessive bureaucracy and returning into wrong patterns of leadership. Even with a strong emphasis on formation for the Clinical Council, encompassing governance, leadership and decision making, change in behavior and habits is difficult to reach.
Family Health Units appear to be based on a more personal contact between health profes-sionals than it is used to happen in case of health centers. Good communication is a principle of teamwork and professionals among USF, in order to comply with the common objectives, need to work together. This may be facilitated by the fact of having known each other previously: a good experience and common trust drives into developing and submitting the application for the USF. There is surely a group of professionals unable, due to various reasons, to join existing units, what is a limitation and a threat to the system and such risk needs to be recognized. Moreover, actual professionals’ development perspectives should be more attractive. Health professionals have, in fact, pledged by law one week in a year for training, but their career offers a limited number of stages2.
What is still in development and requires more attention is the communication between various nodes of the system. Decentralization so far has not been fully possible and cooperation between hospitals and primary care services either between primary care actors has not yet been satisfactorily attained. At present, with a number of information-communication systems and technologies, none allows health professionals to have an access to a detailed patient’s path within 2 The career of nurses, for instance, has been limited into two levels only, of which the second one is obtained with years of
the whole system. It would be an effective counteract to duplications of medical treatments and exams. It is vital to configure the cooperation patterns in order to guarantee continuity of care. An actual focus should be directed into knowledge flow and incorporation of good and verified methods into clinical practice.
The complexity of the system makes it challenging to create fair financing and control tools. There is a general pressure on further expenditure (while expenditure on health as a share of GDP is one of the highest), which is understandable given that in an ageing population a demand for certain health services rises, but perhaps there is a way to deal with problems of inefficiency and improve health outcomes and population health status without necessarily an increase on spending.
It would be also interesting to know how relevant patients’ opinions are to USF and whether their comments and remarks are in practice taken into account.
5. Conclusions
There has been a significant shift in primary care provision in Portugal in the last years. Providing quality care and assuring patient satisfaction, while maintaining sustainability of health and social systems is a challenge to countries. Portugal continues to lag behind others in what efficiency and effectiveness of care concern. The undertaken reform, due to its strategic assumptions, is unique in the history of the Portuguese health system. Respective legislation has been preceded by practical verification of the possible solutions that might be applicable to the existing situation with a high level of flexibility. Taken into the public debate, the roots of the new model of the primary health care reside in the society as for the society it has been designed. The prime focus is addressed to a patient and patients’ involvement is considered to be necessarily more perceptible than it is now in order to better suit the real needs.
It took time to formally establish the model’s elements: care providers, governing bodies and support entities. In fact, all the entities others than Family Health Units were appointed recently. The short time spam since then makes impossible drawing deeper conclusions on their functioning in a real-setting.
So far, it seems that Family Health Units, within their range of responsibilities, constitute satisfactory solutions and with good prognoses for the future. Recent evidence indicates high level of satisfaction among both patients and health professionals. Financial personal incentives offered within Model B of USF increase motivation of professionals, who deem the system attractive since the number of USF candidatures has been significantly increasing. On institutional side, through incentives conferred after fulfilling the quality indicators, USF are able to invest in improvement of facilities and professional development of employees. This new approach promoting communication and teamwork shall support coordination among health care providers in order to prevent problems related to duplication of medical test and conflicting diagnoses.
The objective behind this primary health care reform is to make the health care system sus-tainable in a long-term, stabilizing the family budget and the economy. What can be confirmed is that at the present moment the new model does not origin a further cost increase, nevertheless, it is not sustainable yet. Results are somehow encouraging but a number of pending issues to be dealt with is still awaiting. The reform represents potentials that should not be mishandled through incorrect governance or political issues.
6. Literature
1. Angelmar R., Berman P.C. Patient empowerment and efficient health outcomes. 2007 Re-trieved from http://www.drmed.org/index.php?k=10&n=344, accessed on September 13, 2010 2. ARS Norte, IP. Contratualização com Unidade de Saúde Familiar. Relatório 2009. Porto,
2010. Retrieved from http://portal.arsnorte.min-saude.pt/portal/page/portal/ ARS-Norte/Noticias, accessed September 15, 2010.
3. ARS Norte, IP. Relatório de Actividades de 2008. Porto, 2009. Retrieved from http://portal.arsnorte.min-saude.pt/portal/page/portal/ARSNorte/Documentos/Relat%
C3%B3rios, accessed on September 5, 2010.
4. Barros P., de Almeida Simões J. Portugal: Health system review. Health systems in transition.World Health Organization Regional Office for Europe on behalf of the European Observatory of Health Systems and Policies. Copenhagen, 2007. p.10–140.
5. Bentes, M., et al. Health care systems in transition: Portugal. World Health Organization Regional Office for Europe on behalf of the European Observatory of Health Systems and Policies. Copenhagen, 2004. p. 14–37.
6. Coelho E., Magalhães M.G., Bravo J.M. Mortality projections in Portugal.
EUROSTAT/UNECE. Lisbon, 2010. p. 1–4 Retrieved from
http://www.unece.org/stats/documents/2010.04.projections.htm, accessed on September 1, 2010.
7. Correia I., Veiga P. Geographic distribution of physicians in Portugal. The European Journal of Health Economics. 2010. 11(4): p. 383–393.
8. Direcção Geral da Saúde. Plano Nacional de Saúde 2004–2010: mais saúde para todos. Ministério de Saúde. Lisboa 2004. Retrieved from http://www.dgsaude.min saude.pt/pns/capa.html, accessed on September 2, 2010.
9. European Parliament. Directorate General for Research. Health care systems in the EU. A comparative study. Public Health and Consumer Protection Series. Luxembourg, 1998. p. 105–111.
10. Eurostat. Perceptions on health and access to health care in the EU-25 in 2007. Luxembourg 2009. Retrieved from http://epp.eurostat.ec.europa.eu/portal/page/portal/product _details/publication?p_product_code=KS-SF-09-024, accessed on August 18, 2010
11. Ferreira A.S. De que falamos quando falamos de regulação em saúde? Análise Social. 2004. Vol. XXXIX(171): p. 313–334.
12. Ferrinho P., et al. Dual practice in the health sector review of the evidence. Human Resources for Health. 2004. 2(1).
13. Ferrinho P., et al. Multiple employment in the health sector in Portugal. Cah Sociol Demogr Med. 2007. 47(3): p. 331–346.
14. Gross R., Tabenkin H., Brammli-Greenberg S. Who needs a gatekeeper. Patients’ views of the role of the primary care physician. Family Practice. 2000. 17(3): p. 222–229.
15. OECD/IRDES. OECD Health Data 2010: Statistics and Indicators. Paris, 2010.Retrieved from http://www.oecd.org/document/30/0,3343,en_2649_34631_12968734_1_1_1_374 07,00.html, accessed on September 1, 2010.
16. Oliveira M., Bevan G. Measuring geographic inequities in the Portuguese health care system: an estimation of hospital care needs. Health Policy. 2003. Vol. 66: p. 279–293.
17. OPSS. Relatório Primavera 2010. Lisboa, 2010. Retrieved from http://www.observaport.org/rp2010, accessed on August 31, 2010.
18. Relatório do Grupo Consultivo para a Reforma dos Cuidados de Saúde Primários. Acontecimento extraordinário. SNS – proximidade com qualidade. 2009. p. 11–40 Retrieved from http://www.portaldasaude.pt/portal/conteudos/a+saude+em+portugal/noticias/arquivo /2009/3/sns+proximidade.htm, accessed on September 14, 2010.
19. Santana P. Poverty, social exclusion and health in Portugal. Social Science and Medicine. 2002. 55(1): p. 33–45.
20. Wensing M., Elwyn G. Research on patient’s views in the evaluation and improvement of quality of care. Quality and Safety in Health Care. 2002. 11(2): p. 153–157.
21. WHO/UNICEF. Declaration of Alma-Ata. International Conference on Primary Health Care. Alma-Ata, 1978. Retrieved from http://www.euro.who.int/en/who-we-are/policydocuments/declaration-of-alma-ata,-1978, accessed on August 20, 2010.
22. World Health Organization. The World Health Report 2008: Primary Health Care Now More Than Ever. Geneva, 2008. p. 8–38.
23. http://www.mcsp.min-saude.pt/engine.php?cat=32, accessed on September 10, 2010. 24. http://www.mcsp.min-saude.pt/engine.php?id=2770, accessed on September 7, 2010.
KU SKUPIONEJ NA PACJENCIE I EKONOMICZNIE ZRÓWNOWAONEJ OPIECE: OSI GNICIA REFORMY SYSTEMU PODSTAWOWEJ OPIEKI
ZDROWOTNEJ W PORTUGALII Streszczenie
Silniejsza presja na system opieki zdrowotnej i społecznej wynikająca ze zmian demograficznych, społecznych, ekonomicznych i epidemiologicznych jest generalną tendencją, z jaką mierzą siĊ wspołczeĞnie rządy na Ğwiecie i Portugalia nie stanowi tutaj wyjątku. W Ğwietle ograniczeĔ budĪetowych oraz rzadkoĞci zasobów asortyment obiecujących rozwiązaĔ wydaje siĊ ograniczony.
Pewne przyczyny, począwszy od nieskutecznoĞci i nieudolnoĞci systemu, poprzez wzrastające koszty operacyjne po niską dostĊpnoĞü oraz brak satysfakcji ze strony i pacjentów, i specjalistów, doprowadziły do ponownego rozwaĪenia struktury poli-tyki zdrowia.
Celem poniĪszego artukułu jest zaprezentowanie postĊpów najnowszej reformy mającej na celu przebudowanie podstawowej opieki zdrowotnej w Portugalii, gwarantując dostĊp, jakoĞü serwisu i satysfakcjĊ pacjentom, motywacjĊ pra-cownikom oraz stabilnoĞü systemową.
Przeprowadzona pomyĞlnie, reforma moĪe zaowocowaü zmianami w zakresie organizacyjnych aspektów zarządzania, a w Ğrednim i długim wymiarze czasu do-prowadziü do poprawy stanu zdrowia i, w konsekwencji, poprawy jakoĞci Īycia społeczeĔstwa. Jest to wiĊc kwestia jak najbardziej ekonomiczna a jej znaczenie powinno zostaü uznane i wsparte przez władze.
Pewne osiągniĊcia i praktyki tutaj zaprezentowane mogą zostaü potencjalnie rozwaĪone i przejĊte przez systemy bedące w fazie przekształceĔ, mając na uwadze, Īe dziedzina ta jest wysoce zaleĪna od kraju, tak wiĊc powinny one zostaü ostatecznie dopasowane do specyfiki systemu, warunków gospodarczych i cyklu koniunkural-nego, oraz kultury.
Słowa kluczowe: podstawowa opieka zdrowotna, centrum zdrowia, pacjent, reforma, system, Portugalia
Nina Szczygiel
Department of Economic, Management and Industrial Engineering
GOVCOPP – Research Unit on Governance, Competitiveness and Public Policies University of Aveiro
Campus Universitário de Santiago, 3810-193 Aveiro, Portugal nina.szczygiel@ua.pt
Dulce Pinto
Administração Geral de Saúde do Norte, IP
Rua Santa Catarina 1288 4000-447 Porto, Portugal enfdulcepinto@gmail.com Silvina Santana
Department of Economic, Management and Industrial Engineering IEETA – Institute of Electronics and Telematics Engineering of Aveiro
GOVCOPP – Research Unit on Governance, Competitiveness and Public Policies University of Aveiro
Campus Universitário de Santiago, 3810-193 Aveiro, Portugal silvina.santana@ua.pt
