Healthcare Equity and Commissioning: A Four-Year National Analysis of Portuguese Primary Healthcare Units.

Equal and adequate access to healthcare is one of the pillars of Portuguese health policy. Despite the controversy over commissioning processes' contribution to equity in health, this article aims to clarify the relationship between socio-economic factors and the results of primary healthcare (PHC) commissioning indicators through an analysis of four years of data from all PHC units in Portugal. The factor that presents a statistically significant relationship with a greater number of indicators is the organizational model. Since the reform of PHC services in 2005, a new type of unit was introduced: the family health unit (USF). At the time of the study, these units covered 58.1% of the population and achieved better indicator results. In most cases, the evolution of the results achieved by commissioning seems to be similar in different analyzed contexts. Nevertheless, the percentage of patients of a non-Portuguese nationality and the population density were analyzed, and a widening of discrepancies was observed in 23.3% of the cases. The commissioning indicators were statistically related to the studied context factors, and some of these, such as the nurse home visits indicator, are more sensitive to context than others. There is no evidence that the best results were achieved at the expense of worse healthcare being offered to vulnerable populations, and there was no association with a reduction in inequalities in healthcare. It would be valuable if the Portuguese Government could stimulate the increase in the number of working USFs, especially in low-density areas, considering that they can achieve better results with lower costs for medicines and diagnostic tests.

Organisation of the State, model of health system and COVID-19 health outcomes in six European countries, during the first months of the COVID-19 epidemic in 2020.

The time and type of the States' responses to the COVID-19 pandemic varied with the severity of the epidemiological situation, the perceived risk, the political organisation and the model of health system of the country. We discuss the response of Germany, Spain, France, Italy, Portugal and the United Kingdom during the first months of the COVID-19 epidemic in 2020, considering the political organisation of the country and its health system model. We analyse public health measures implemented to contain or mitigate the pandemic, as well as those related to governance, resources and reorganisation of services, financing mechanisms, response of the health system itself and health outcomes. To measure the burden of COVID-19, we use several indicators. The adoption of measures, to contain and mitigate epidemic varied in degree and time of adoption. All countries reorganised their governance structure and the provision of care, despite the differences in political models and health systems (ranging from a more unitary and centralised political organisational model-France and Portugal; to a decentralised matrix-Germany, Spain, Italy and the United Kingdom). Rather than the differences in political models and health systems, the explanation for the success in tackling the epidemic seems to lay in other social determinants of health.

The effect of commissioning on Portuguese Primary Health Care units' performance: A four-year national analysis.

BACKGROUND: Portugal underwent a paradigmatic Primary Health Care (PHC) reform in 2005. The reform implemented better health information systems, goal-oriented management, pay-for-performance schemes, functional autonomy for the front-line units, and the general adoption of commissioning processes. Since the implementation of the reform, the same set of indicators have been monitored nationally every year. However, from 2014-2016, the five Regional Health Administrations could individually select part of set of indicators to be commissioned. As the same some indicators were used commissioned in some regions, but not in others, a natural experimental setting to observe the impact of commissioning on the results by comparing the performance of commissioned versus non-commissioned indicators emerged and the effects of commissioning on PHC performance could be evaluated. AIM: Our article aims to clarify the effect of commissioning on the results achieved by PHC units in Portugal following the implementation of the reform. RESULTS: In general, the indicator values improved with time in the three types of units that existed after the reform. However, Model B Family Health Units ('Unidades de Saúde Familiar' or USFs that use pay-for-performance and are more mature) obtained the highest absolute indicator values, followed by Model A USFs (newer units with a fixed salary) and Personalised Health Care Units ('Unidades de Cuidados de Saúde Personalizados' that were created under the model before the reform and offer a fixed salary), respectively. CONCLUSION: The results show a general increase in indicators in all PHC units. However, the indicators used in the commissioning processes exhibited a greater increase. There was no evidence that the better results exhibited by the commissioned indicators were achieved at the expense of a detrimental effect on non-commissioned indicators.

Validation of the Portuguese Version of the Postoperative Quality Recovery Scale (PostopQRS).

INTRODUCTION: The Postoperative Quality Recovery Scale is a brief instrument of six domains designed to assess quality of recovery from early to long term after surgery. This study aims to validate the Portuguese version of the Postoperative Quality Recovery Scale. MATERIAL AND METHODS: In this observational study 101 adult patients undergoing elective surgery completed the Postoperative Quality Recovery Scale at 15 minutes and 40 minutes, one and three days after surgery. Three constructs were assessed for validity: increased recovery over time; effect of gender and recovery association with muscle strength. Reliability, responsiveness, feasibility and acceptability were also assessed. RESULTS: Construct validity was shown by increased recovery over time; worse recovery for female patients in emotive, nociceptive, activities of daily living and overall recovery; improved muscle strength in recovered patients. Internal consistency for activities of daily living was acceptable at all-time points (Cronbach's α value of 0.772 or higher), indicating scale reliability. The scale was able to detect differences in postoperative quality of recovery between the neuromuscular blockade reversal agents, neostigmine and sugammadex, indicating scale responsiveness. The time to conduct the Portuguese version at baseline was 95 - 581 seconds (median 319 seconds) and it was reduced with subsequent assessments. The proportion of patients completing all scale items was 87%, 75%, 65% and 94% for the four time periods evaluated, indicating scale feasibility and acceptability. DISCUSSION: This study shows that the Portuguese version of the Postoperative Quality Recovery Scale, demonstrates construct validity, reliability, responsiveness, feasibility and acceptability. CONCLUSIONS: This study allowed validation of the Portuguese version of the Postoperative Quality Recovery Scale.

Introdução: A Escala da Qualidade da Recuperação Pós-Operatória é um instrumento de seis domínios, desenhada para avaliar a qualidade da recuperação no período pós-operatório precoce e tardio. Este estudo teve como objetivo validar a versão portuguesa da Escala da Qualidade da Recuperação Pós-Operatória. Material e Métodos: Neste estudo observacional foi obtida uma amostra de 101 doentes adultos submetidos a cirurgia eletiva e que preencheu a Escala da Qualidade da Recuperação Pós-Operatória aos 15 e 40 minutos, um e três dias após a cirurgia. Três teorias foram avaliadas para aferir a validade teórica da escala: aumento da recuperação ao longo do tempo, efeito do género e a associação da recuperação com a força muscular. Foram também avaliadas a fiabilidade, poder de resposta, viabilidade e aceitabilidade. Resultados: A validade teórica foi demonstrada pelo aumento da recuperação ao longo do tempo, assim como uma pior recuperação para doentes do sexo feminino em atividades emotivas, nociceptivas, diárias e de recuperação geral. Detetou-se ainda uma melhoria da força muscular em doentes recuperados. A coerência interna no domínio das atividades da vida diária foi aceitável em todos os tempos (valor α de Cronbach de 0,772 ou superior), indicando a fiabilidade da escala. Com esta escala foi possível detetar diferenças na qualidade pós-operatória da recuperação entre os agentes de reversão de bloqueio neuromuscular, a neostigmina e o sugammadex, indicando que a escala apresenta poder de resposta. O tempo para aplicar a versão portuguesa no período inicial (baseline) foi de 95 - 581 segundos (mediana 319 segundos) com uma diminuição em avaliações subsequentes. A proporção de doentes que completaram todos os itens da escala foi de 87%, 75%, 65% e 94% nos quatro períodos avaliados, indicando viabilidade e aceitabilidade da escala. Discussão: A versão portuguesa da Escala da Qualidade da Recuperação Pós-Operatória demonstrou ter validade, fiabilidade, poder de resposta, viabilidade e aceitabilidade. Conclusões: Este estudo permitiu a validação da versão Portuguesa da Escala da Qualidade da Recuperação Pós-Operatória.

Primary Health Care Reform in Portugal: Portuguese, modern and innovative. / A Reforma dos Cuidados de Saúde Primários em Portugal: portuguesa, moderna e inovadora.

The 2005 Portuguese primary health care (CSP) reform was one of the most successful reforms of the country's public services. The most relevant event was the establishment of Family Health Units (USF): voluntary and self-organized multidisciplinary teams that provide customized medical and nursing care to a group of people. Then, the remaining realms of CSP were reorganized with the establishment of Health Center Clusters (ACeS). Clinical governance was implemented aiming at achieving health gains by improving quality and participation and accountability of all. This paper aims to characterize the 2005 reform of Portuguese CSP with an analysis of its systemic and local realms. This is a case study of a CSP reform of a health system with documentary analysis and description of one of its facilities. This reform was Portuguese, modern and innovative. Portuguese by not breaking completely with the past, modern because it has adhered to technology and networking, and innovative because it broke with the traditional hierarchized model. It fulfilled the goal of a reform: it achieved improvements with greater satisfaction of all and health gains.

A Reforma dos Cuidados de Saúde Primários em Portugal: portuguesa, moderna e inovadora / Primary Health Care Reform in Portugal: Portuguese, modern and innovative

Resumo A reforma de 2005 dos cuidados de saúde primários (CSP) portugueses foi uma das mais bem-sucedidas feitas nos serviços públicos do país. O acontecimento mais relevante foi a constituição das Unidades de Saúde Familiar (USF): equipes multidisciplinares voluntárias e auto-organizadas, que prestam cuidados médicos e de enfermagem personalizados a um conjunto de pessoas. Num segundo momento reorganizaram-se as restantes dimensões dos CSP com a criação dos Agrupamentos de Centros de Saúde (ACeS). Apostou-se na governação clínica procurando-se obter ganhos em saúde pela melhoria da qualidade e da participação e responsabilização de todos. Este artigo tem por objetivo caracterizar a reforma de 2005 dos CSP Portugueses com a análise das suas dimensões sistêmica e local. Trata-se de um estudo de caso de uma reforma na área dos CSP de um sistema de saúde com análise documental e descrição de uma de suas unidades. Esta reforma foi portuguesa, moderna e inovadora. Portuguesa ao não quebrar completamente com o passado, moderna porque se aliou à tecnologia e ao trabalho em rede, e inovadora porque ultrapassou o modelo hierarquizado tradicional. Cumpriu o objetivo de uma reforma: conseguiu melhorias com maior satisfação de todos e ganhos em saúde.

Abstract The 2005 Portuguese primary health care (CSP) reform was one of the most successful reforms of the country's public services. The most relevant event was the establishment of Family Health Units (USF): voluntary and self-organized multidisciplinary teams that provide customized medical and nursing care to a group of people. Then, the remaining realms of CSP were reorganized with the establishment of Health Center Clusters (ACeS). Clinical governance was implemented aiming at achieving health gains by improving quality and participation and accountability of all. This paper aims to characterize the 2005 reform of Portuguese CSP with an analysis of its systemic and local realms. This is a case study of a CSP reform of a health system with documentary analysis and description of one of its facilities. This reform was Portuguese, modern and innovative. Portuguese by not breaking completely with the past, modern because it has adhered to technology and networking, and innovative because it broke with the traditional hierarchized model. It fulfilled the goal of a reform: it achieved improvements with greater satisfaction of all and health gains.

The state of the health workforce in Portugal.

This paper discusses the state of the health workforce in Portugal's mainland during the past four decades. Healthcare workers represent 3.76% of the Portuguese workforce. All health professional groups significantly increased since 1960. Growth has been continuous for hospital physicians and nurses in general, as well as for primary care nurses. Primary care physicians are an exception, growing until the late 1970s but steadily decreasing afterwards. The density of physicians per 1000 inhabitants is above the European average. For nurses, Portugal is at the lowest European limit. However, the regional distribution of nurses, and also of pharmacists, across the country is more equitable than for physicians. The number of workers employed by the Health Ministry has grown by 44.6% between 1985 and 2004, with 127 013 employees registered in 2004. There has also been a marked increase in the number of female employees. Only 23.6% of healthcare workers employed by the Health Ministry, work at primary care level. Data on the private sector is insufficient in spite of its rising importance. The right number and mix of healthcare workers for an optimal healthcare system performance is a complex question and answering it requires an adequate information system. Portugal does not have such a system yet.

Professionals entering and leaving the Portuguese health services system.

In Portugal, the healthcare sector demand for professionals has traditionally outweighed the supply for physicians, nurses and health technicians. However, the capacity of the National Health Service, the main healthcare sector employer, to absorb new professionals is apparently decreasing, and the demand for professionals in the private sector is unclear, but it seems to be growing. With regard to physicians, demand seems to persistently exceed supply, as many physicians work in several institutions or work overtime in the public sector, and the number of foreign physicians practicing in Portugal is increasing. In recent years, the number of medical schools and medical graduates increased, but it may not be sufficient to meet future needs. This paper is limited by the lack of comprehensive data on the private sector and on the number of professionals moving between the public and private sectors. These data are important for the planning and the decision-making process. Human resources policies, supported by an adequate health information system, are fundamental steps for the improvement of the performance of the healthcare system.

Multiple employment in the health sector in Portugal.

This paper reports on multiple employment among Portuguese health sector workers, using data obtained from six studies. The methodological aspects of these studies are briefly summarized. The prevalence among the study populations varies between 5 and 80%. When the first job is in the public sector, the site of additional employment is most frequently another public sector facility. Multiple employment is more prevalent among hospital workers; it is more frequent among those working shifts or part-time, and least frequent among professionals with a contract that requires exclusivity. Physicians with multiple jobs were more likely to have low expectations of getting promoted and to assess the rewards for their work as inadequate. For most nurses the salary increment resulting from multiple employment was less than their public sector salary. For both groups, improving income levels and higher job satisfaction were important reasons to seek additional employment. For physicians working in public services, access to more professional autonomy was an important reason for seeking additional employment in the private sector.

The health status of Portuguese healthcare professionals.

Several studies have shown that healthcare professionals are at greater risk than the rest of the population of having certain health problems due to the specificity of their workplace and the physical and psychological demands of their work. Additionally, healthcare professionals seem to behave differently when seeking health care. Several studies also indicate that the health of healthcare professionals has an impact on the performance of services and on the health of the population. The present paper analyzes morbidity patterns, health behaviors and lifestyles, self-perceived health status and health service utilization among healthcare professionals, by using the Portuguese 1999 National Health Survey. Results differ from those found in international studies. Portuguese healthcare professionals did not suffer more from some health problems than non-healthcare professionals. Healthcare professionals tended to assess their health as good and better as that of other workers. They also reported healthier behaviors (smoked less, drank less and practiced exercise more often) and missed fewer workdays due to sickness. The percentage of healthcare professionals suffering from back pain was lower than the percentage of other workers but they started to complain earlier.

Dual practice in the health sector: review of the evidence.

This paper reports on income generation practices among civil servants in the health sector, with a particular emphasis on dual practice. It first approaches the subject of public-private overlap. Thereafter it focuses on coping strategies in general and then on dual practice in particular.To compensate for unrealistically low salaries, health workers rely on individual coping strategies. Many clinicians combine salaried, public-sector clinical work with a fee-for-service private clientele. This dual practice is often a means by which health workers try to meet their survival needs, reflecting the inability of health ministries to ensure adequate salaries and working conditions.Dual practice may be considered present in most countries, if not all. Nevertheless, there is surprisingly little hard evidence about the extent to which health workers resort to dual practice, about the balance of economic and other motives for doing so, or about the consequences for the proper use of the scarce public resources dedicated to health.In this paper dual practice is approached from six different perspectives: (1) conceptual, regarding what is meant by dual practice; (2) descriptive, trying to develop a typology of dual practices; (3) quantitative, trying to determine its prevalence; (4) impact on personal income, the health care system and health status; (5) qualitative, looking at the reasons why practitioners so frequently remain in public practice while also working in the private sector and at contextual, personal life, institutional and professional factors that make it easier or more difficult to have dual practices; and (6) possible interventions to deal with dual practice.

[Policy and management of human resources in the health care system of Portugal]. / Politique et gestion des ressources humaines dans le secteur de la santé au Portugal. Controverses et problématiques actuelles.

Portugal has adopted the Beveridgian model of National Health Service after the revolution of 1974. However, certain principles have been proclaimed long before that date. In particular, equity in access to and solidarity in financing of health care have been emphasized since many decades, although not yet completely implemented nowadays. The NHS is managed by the Ministry of Health who employed in 1999 approximatively 115,500 professionals. In 1998, the Portuguese NHS had 245 medical doctors and 334 nurses per 100,000 population. As concerns ambulatory care, the NHS deploys throughout the country health centers where GPs act as gatekeepers. The NHS is plagued by several chronic shortcomings: politics and politicians are deeply involved in its decision-making process, its information system is weak, manpower planning is lacking, the medical careers outside hospitals are not appreciated, continuing education of health workers is neglected, the working conditions and skill-mix are deteriorating and, finally, the remuneration system is outdated.

Patterns of perceptions of workplace violence in the Portuguese health care sector.

This article characterizes the problem of violence against health professionals in the workplace (VAHPITWP) in selected settings in Portugal. It addresses the questions of what types of violence are most frequent and who are the most affected health professionals.Three methodological approaches were followed: (i) documentary studies, (ii) a questionnaire-based hospital and health centre (HC) complex case study and (iii) semi-structured interviews with stakeholders.Of the different types of violence, all our study approaches confirm that verbal violence is the most frequent. Discrimination, not infrequent in the hospital, seems to be underestimated by the stakeholders interviewed. Violence seems much more frequent in the HC than in the hospital. In the HC, all types of violence are also most frequently directed against female health workers and, in the hospital, against male workers.These studies allow us to conclude that violence is frequent but underreported.