What Bases for Health in Portugal? – Observer
The Basic Health Law (LBS) is a set of legal provisions that establish the general framework of health policy in Portugal, establishing the general principles that structure the functioning of the National Health Service (SNS) and the relationship between the State and citizens on health care. It was created with the aim of ensuring access by all Portuguese citizens to quality health care, as well as guaranteeing the sustainability and efficiency of the Portuguese health system, which is why it also establishes the responsibilities and powers of the different entities and institutions that comprise it. : health services, health professionals and health authorities. The “new” Basic Health Law was published in Diário da República in September 2019, revoking the Basic Law dated 1990 and revised in 2002.
One of the ideological flags of the “new” Basic Health Law concerns the relationship between the SNS and the private sector. In its Base 6 it is highlighted that “the responsibility of the State for the realization of the right to health protection is obtained through the SNS and other public services, being able, in a supplementary and temporary way, agreements with private entities and the social sector”. Thus, one of the key ideas of the 2002 revision of the 1990 Basic Law falls to the ground, in which one of the priorities of the tutelage was the “deepening of innovative experiences of management of a business nature and the mobilization of non-public investment in the system of health, making the private and social sectors increasingly participate in the different models and contractual forms, with a view to obtaining a progressive rationalization of the functions of financing and contracting and of the function of providing health care”. Part of the motivations for breaking the progressive symbiotic relationship that existed between the SNS and the private sector included the allegation that the strong growth of the private health sector had a negative impact on the SNS, “mainly in terms of competition for health professionals and demand skimming health”.
The results of 43 years of SNS are unequivocally positive. However, it is easy to understand today, in 2022, that the current model cannot respond to present and future health needs. Why? There are several shortcomings identified several years ago, which surely would have already been resolved if the solution were easy or existing: insufficient funding to meet the needs of the population and to invest in new technologies and equipment, lack of health professionals in some areas of the country , inequalities in access to health care (especially in the interior regions and among the most independent groups in society), the inefficiency of the health system and the aging of the population. But denying the positive contributions of some recent health policies, such as public-private partnerships, is necessary and does not help to improve health in Portugal.
Health PPPs are agreed between the public and private sectors for the delivery of health services, with the aim of leveraging the resources and expertise of the private sector to improve efficiency and quality, while still ensuring universal access and the protection of users’ rights. Health PPPs can come in different formats, such as the construction and management of public hospitals by the private sector, the provision of health services by private companies in public units, or the provision of health services in private units to the public sector. . Its implementation is controversial, with the discussion about its usefulness often bumping into ideological prejudices related to doctrinal policies.
More than ideological prejudices, facts matter. An analysis by the Court of Auditors of some of the example cases of PPP in health in the last decade (Hospitals in Braga, Vila Franca de Xira, Loures and Cascais) underlined that this management model generated savings for the State, was generally more efficient than the average of comparable publicly managed hospitals, emphasizing a positive assessment of the performance of the PPP in the hospital management component, both from the perspective of the State and from the perspective of the independent external estimates that were produced by it. How can one explain, then, the end of PPPs in Health? If the PPP in Health is associated with very positive results in terms of service quality, user satisfaction and cost, what is the reason for the 2019 LBS to promote an increasing distance from this health management model?
The “new” LBS, in its Base 20, proposes a set of principles that should structure the provision of health care in the SNS: universal (that is, the guarantee of providing care to all people, without discrimination, in conditions of equality and equality), general (in its scope, promoting health, preventing disease and treating and rehabilitating patients) and tending to be free (taking into account the economic and social conditions of citizens). In addition, the importance of integrating care, equity, quality, proximity, financial sustainability and transparency is reinforced. However, we know that this does not happen. Let us reflect on the three examples I have described below.
More than 1.4 million Portuguese people do not have a family doctor (a particularly serious situation in the Lisbon and Tagus Valley areas), which has repercussions on tremendous difficulties in accessing health promotion and disease prevention care, normally provided scope of primary health care, outside the hospital context. The obvious consequence is the need to force a gateway into the health system, which often involves resorting to the emergency service, which overloads these services with a high number of episodes that should not be resolved in an emergency context (with an increase in expenditure for the system and waste of human resources work capacity).
About a third of Portuguese people do not go to Dental Medicine or only do so in an emergency situation, and in 30% of these people the main reason that keeps them away from adequate oral health is financial reasons. Oral health in Portugal has had a troubled path, which begins with not having been included in the creation of the SNS (which was intended to have “general” coverage) and with the failure of the Programa de Saúde Oral para Todos, a project created in 2017 that intended to integrate dentists in clusters of health centers, with multiple factors that led to this failure and which included the inability to create careers and disabling conditions to retain dentists.
Despite Health budget reinforcements, families continue to be responsible for paying 27% of health expenses. Based on data from 2020, when thinking about current health expenditure, the SNS and the Regional Health Services of the Azores and Madeira thought with 56% for its funding. In other words, in view of the flaws already identified in the accessibility and universality of health care provided by the SNS, the 27% of direct payments for expenses on health requests to Families seem disproportionate and did not correspond to the objectives that the SNS proposes.
Base 23 of the LBS presents the financing model for the SNS, which should be “guaranteed by funds from the State Budget”, which should allow “the SNS to be endowed with the necessary resources to fulfill its functions and objectives”. In other words, as is evident, the Portuguese SNS is financed by taxes. The SNS coexists with two other systems: the health subsystems (which provided coverage to certain professions or sectors, as is the case with the civil servants and banking sector employees) and the private voluntary health insurance regimes. It is interesting to point out that health subsystems (such as ADSE) and health insurance facilitate access to hospital treatments and outpatient consultations in the vast national network of private health institutions. It is therefore not surprising that, given the problem of access to healthcare provided by the SNS, more than five million Portuguese have private insurance or a healthcare subsystem, underlining that private hospitals are the gateway to healthcare for more and more Portuguese.
What is urgent to change? How can an amendment to the current LBS promote the necessary change in healthcare in Portugal? How to have health care that reaches more people, that promotes health and treats disease in a timely, convenient and efficient way? People will have to be at the center of the organization of the health sector, with a strong commitment to promoting health literacy and promoting freedom of choice in health care. The existence of an SNS that strictly articulates with the social and private sectors must be ensured to guarantee access to health services to all those who need them. For this, each person must have the freedom and responsibility to choose a health subsystem, which organizes its regional care observation network in a transparent and objective manner and with the safeguard of ensuring comprehensive health care and in accordance with the best practices. existing. As far as funding is concerned, tax contributions to Health cannot be diluted in total tax revenue and it would be desirable to transform Health into a subsector independent of the State, similar to Social Security. Each contributor would deduct a percentage of his salary for the health subsystem in which he was enrolled, assuring the State the contribution of those who could not pay.
It is the responsibility of all of us to realize the need to change the organization and funding of the National Health Service. This is the decisive path we must take to ensure the health of future generations.