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Portugal Health system review Vol. 13 No. 4 2011 Health Systems in Transition Pedro Pita Barros Sara Ribeirinho Machado Jorge de Almeida Simões

Portugal HiT (2011) _ Health System Review

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Page 1: Portugal HiT (2011) _ Health System Review

PortugalHealth system review

Vol. 13 No. 4 2011Health Systems in Transition

Pedro Pita BarrosSara Ribeirinho MachadoJorge de Almeida Simões

Page 2: Portugal HiT (2011) _ Health System Review

Sara Allin (Editor) and Elias Mossialos (Editor in chief) wereresponsible for this HiT

Editorial Board

Editor in chiefElias Mossialos, London School of Economics and Political Science, United Kingdom

Series editorsReinhard Busse, Berlin University of Technology, GermanyJosep Figueras, European Observatory on Health Systems and PoliciesMartin McKee, London School of Hygiene & Tropical Medicine, United KingdomRichard Saltman, Emory University, United States

Editorial teamSara Allin, University of Toronto, CanadaMatthew Gaskins, Berlin University of Technology, GermanyCristina Hernández-Quevedo, European Observatory on Health Systems and PoliciesAnna Maresso, European Observatory on Health Systems and PoliciesDavid McDaid, European Observatory on Health Systems and PoliciesSherry Merkur, European Observatory on Health Systems and PoliciesPhilipa Mladovsky, European Observatory on Health Systems and PoliciesBernd Rechel, European Observatory on Health Systems and PoliciesErica Richardson, European Observatory on Health Systems and PoliciesSarah Thomson, European Observatory on Health Systems and PoliciesEwout van Ginneken, Berlin University of Technology, Germany

International advisory boardTit Albreht, Institute of Public Health, SloveniaCarlos Alvarez-Dardet Díaz, University of Alicante, SpainRifat Atun, Global Fund, SwitzerlandJohan Calltorp, Nordic School of Public Health, SwedenArmin Fidler, The World BankColleen Flood, University of Toronto, CanadaPéter Gaál, Semmelweis University, HungaryUnto Häkkinen, Centre for Health Economics at Stakes, FinlandWilliam Hsiao, Harvard University, United StatesAlan Krasnik, University of Copenhagen, DenmarkJoseph Kutzin, World Health Organization Regional Office for EuropeSoonman Kwon, Seoul National University, Republic of KoreaJohn Lavis, McMaster University, CanadaVivien Lin, La Trobe University, AustraliaGreg Marchildon, University of Regina, CanadaAlan Maynard, University of York, United KingdomNata Menabde, World Health Organization Regional Office for EuropeEllen Nolte, Rand Corporation, United KingdomCharles Normand, University of Dublin, IrelandRobin Osborn, The Commonwealth Fund, United StatesDominique Polton, National Health Insurance Fund for Salaried Staff (CNAMTS), FranceSophia Schlette, Health Policy Monitor, GermanyIgor Sheiman, Higher School of Economics, Russian FederationPeter C. Smith, Imperial College, United KingdomWynand P.M.M. van de Ven, Erasmus University, The NetherlandsWitold Zatonski, Marie Sklodowska-Curie Memorial Cancer Centre, Poland

Page 3: Portugal HiT (2011) _ Health System Review

Health Systemsin Transition3HGUR�3LWD�%DUURV��8QLYHUVLGDGH�1RYD�GH�/LVERD�DQG�&HQWUH�IRU�(FRQRPLF�3ROLF\�5HVHDUFK��/RQGRQ

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Health System Review2011

Portugal:

The European Observatory on Health Systems and Policies is a partnership between the WHO Regional Office for Europe, the Governments of Belgium, Finland, Ireland, the Netherlands, Norway, Slovenia, Spain, Sweden and the Veneto Region of Italy, the European Commission, the European Investment Bank, the World Bank, UNCAM (French National Union of Health Insurance Funds), the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.

Page 4: Portugal HiT (2011) _ Health System Review

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© World Health Organization 2011, on behalf of the European Observatory on Health Systems and Policies

All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full.

Please address requests about the publication to: Publications, WHO Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark

Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site (http://www.euro.who.int/pubrequest).

The views expressed by authors or editors do not necessarily represent the decisions or the stated policies of the European Observatory on Health Systems and Policies or any of its partners.

The designations employed and the presentation of the material in this publication do not imply the expression

of any opinion whatsoever on the part of the European Observatory on Health Systems and Policies or any of its partners concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation “country or area” appears in the headings of tables, it covers countries, territories, cities, or areas. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the European Observatory on Health Systems and Policies in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary productsare distinguished by initial capital letters.

The European Observatory on Health Systems and Policies does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use.

Printed and bound in the United Kingdom.

ISSN 1817-6127 Vol. 13 No. 4

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Page 5: Portugal HiT (2011) _ Health System Review

Co

ntents

Contents

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Page 6: Portugal HiT (2011) _ Health System Review

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Page 7: Portugal HiT (2011) _ Health System Review

Preface

Preface

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Page 8: Portugal HiT (2011) _ Health System Review

Health systems in transition Portugalvi

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Page 9: Portugal HiT (2011) _ Health System Review

Ackn

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Page 10: Portugal HiT (2011) _ Health System Review

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Page 11: Portugal HiT (2011) _ Health System Review

List of abb

reviations

List of abbreviations

ACES Groups of primary care centres

ACS High Commissariat for Health

ACSS Central Administration of the Health System

ADFA Health subsystem for the Air Force

ADMA Health subsystem for the Navy

ADME Health subsystem for the Army

ADSE Health subsystem for civil servants

ALOS Average length of stay

APIFARMA Association of Pharmaceutical Companies

ASST Authority for Blood and Transplantation Services

CNS National Health Council

CODU Urgent Patients Orientation Centre

CODU-Mar Urgent Patients Orientation Centre for situations occurring at sea

CRSul Rehabilitation Centre at São Brás de Alportel

CT Computerized (axial) tomography

DALE Disability-adjusted life expectancy

DGH Directorate-General of Health

DMFT Decayed, missing or filled teeth

DRG Diagnosis-related group

ERDF European Regional Development Fund

EU European Union

EU15 EU Member States before May 2004

EU25 EU Member States before January 2007

EU27 EU Member States after January 2007

FNAM National Medical Federation

GDP Gross domestic product

GP General practitioner

GPEARI High Commissioner for Health

HiT Health Systems in Transition

HIV/AIDS Human immunodeficiency virus/Acquired immunodeficiency syndrome

Page 12: Portugal HiT (2011) _ Health System Review

Health systems in transition Portugalx

HRA Health Regulatory Agency

HTA Health technology assessment

IDT National Institute of Drug Addiction

IGAS General Inspectorate of Health-related Activities

IGIF Institute for the Financial Administration of Health

INE National Statistics Institute

INEM National Institute for Medical Emergencies

INFARMED National Authority of Medicines and Health Products

INSA National Institute of Health Dr Ricardo Jorge

IPS Portuguese Blood Institute

IQS Institute for Quality

IT Information technology

MRI Magnetic resonance imaging

NHS National Health Service

NUTS Nomeclature of Territorial Units for Statistics

OECD Organisation for Economic Co-operation and Development

OMD Medical Dentists Federation

ONSA National Health Observatory

OOP Out-of-pocket (payments)

OTC Over-the-counter (pharmaceuticals)

PET Positron emission tomography

PIDDAC Central Administration’s Investment and Development Plan

PPPs Public–private partnerships

PT-ACS Health subsystem for workers of Portugal Telecom

PYLL Potential years of life lost

R&D Research and development

RHA Regional Health Administration

RNCCI National Long-term Care Network

SAD GNR Health subsystem for National Republican Guards

SAD PSP Health subsystem for Police Agents

SAMS Health subsystem for banking and associated insurance employees

SDR Standardized death rate

SG General Secretariat of Health

SIGIC System for management of (waiting list) patients waiting for surgery

SIM Independent Medical Union

SSMJ Health subsystem for employees of the Ministry of Justice

TB Tuberculosis

USF Family health unit

VHI Voluntary health insurance

WHO World Health Organization

WPU Weighted production units

Page 13: Portugal HiT (2011) _ Health System Review

List of tables an

d figures

List of tables and figures

Tables page

Table 1.1 Population/demographic indicators, 1970 to latest available year 4

Table 1.2 Macroeconomic indicators, latest available year 5

Table 1.3 Mortality and health indicators, 1970–2008 (selected years) 7

Table 1.4 Maternal and child health indicators, 1970–2009 (selected years) 8

Table 1.5 Infant mortality rates (per 1 000 live births) by region, 2000–2008 (selected years) 8

Table 1.6 Main causes of death – percentage of total number of deaths, 1990–2009 (selected years) 10

Table 1.7 Main causes of death (standardized mortality rate per 100 000 population), 2005–2008 10

Table 1.8 DALE (years), 1999–2002 11

Table 1.9 WHO Health for All immunization categories (percentage of children under 3 years), 2008 12

Table 1.10 Major factors affecting health status, 2001 and 2006 14

Table 1.11 Oral health, 2002–2006 14

Table 2.1 The health care system: historical background and recent reform trends – timeline 18

Table 3.1 Trends in health expenditure, 2000 to latest available year 52

Table 3.2 Funding mix for the health system (%), 2000–2008 (selected years) 59

Table 3.3 User charges for health services 63

Table 4.1 Number of beds in acute care, specialized hospitals, primary care centres and long-term care institutions in Portugal per 100 000 population, 1995–2008 (selected years) 80

Table 4.2 Operating indicators in Portugal and selected countries, 1990–2007 (selected years) 81

Table 4.3 PPPs in Portugal 83

Table 4.4 Health care personnel, 1990–2008 (selected years) 86

Table 4.5 Foreign physicians working for the NHS, 2004–2007 89

Table 5.1 Number of beds in the long-term care network, 2007–2008 114

Table 6.1 Major policy measures, 2000–2009 120

Page 14: Portugal HiT (2011) _ Health System Review

Health systems in transition Portugalxii

Figures page

Fig. 1.1 Levels of immunization for measles in the WHO European Region (%), 2009 or latest available year 13

Fig. 2.1 Overview chart of the health system 16

Fig. 2.2 Organizational chart of the Ministry of Health 24

Fig. 3.1 Financial flows 53

Fig. 3.2 Health expenditure as a share (%) of GDP in the WHO European Region, 2008 54

Fig. 3.3 Trends in health expenditure as a share (%) of GDP in Portugal and selected countries, 1995–2008 55

Fig. 3.4 Health expenditure in US$ PPP per capita in the WHO European Region, 2008 56

Fig. 3.5 Public sector health expenditure as a share (%) of total health expenditure in the WHO European Region, 2008 57

Fig. 4.1 Beds in acute hospitals per 100 000 population in Portugal and selected countries, 1990–2008 80

Fig. 4.2 Number of physicians per 100 000 population in Portugal and selected countries, 1990 to latest available year 86

Fig. 4.3 Number of nurses per 100 000 population in Portugal and selected countries, 1990 to latest available year 87

Fig. 4.4 Number of physicians and nurses per 100 000 population in the WHO European Region, 2009 or latest available year 88

Fig. 4.5 Number of dentists per 100 000 population in Portugal and selected countries, 1990 to latest available year 89

Fig. 4.6 Number of pharmacists per 100 000 population in Portugal and selected countries, 1990 to latest available year 91

Fig. 5.1 Outpatient contacts per person per year in the WHO European Region, 2009 or latest available year 99

Fig. 9.1 Life expectancy at birth, 1990–2003 138

Fig. 9.2 Life expectancy at birth – forecast, 1990–2030 138

Fig. 9.3 Life expectancy at age 65 – forecast, 1990–2030 139

Fig. 9.4 PYLL, 1990–2003 140

Fig. 9.5 PYLL – forecast, 1990–2030 141

Fig. 9.6 PYLL – health care promotion, 1990–2003 142

Fig. 9.7 PYLL – selected causes, forecast, 1990–2030 142

Fig. 9.8 PYLL – scenarios, 1990–2030 143

Fig. 9.9 PYLL – land transport accidents, 1990–2030 144

Fig. 9.10 SDR – per 100 000 population, 1990–2003 145

Fig. 9.11 SDR – selected causes, forecast, 1990–2030 145

Fig. 9.12 SDR – scenarios, 1990–2030 146

Page 15: Portugal HiT (2011) _ Health System Review

Ab

stract

Abstract

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Page 16: Portugal HiT (2011) _ Health System Review
Page 17: Portugal HiT (2011) _ Health System Review

Execu

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Executive summary

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Page 18: Portugal HiT (2011) _ Health System Review

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1. Introd

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1. Introduction

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1.1 Geography and sociodemography

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Page 22: Portugal HiT (2011) _ Health System Review

Health systems in transition Portugal2

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Health systems in transition Portugal4

Table 1.1Population/demographic indicators, 1970 to latest available year

1970 1980 1990 2000 2005 2009

Age dependency ratio (dependants to working-age population) 0.61 0.59 0.51 0.48 0.49 0.49

Birth rate, crude (per 1 000 people) 20.8 16.2 11.7 11.7 10.4 9.4

Death rate, crude (per 1 000 people) 10.7 9.7 10.3 10.3 10.2 9.8

Fertility rate, total (births per woman) 3.0 2.25 1.57 1.56 1.41 1.32

Population, ages 0–14 (% of total) 28.5 25.8 20.4 16.1 15.6 15.2

Population, ages 15–64 (% of total) 61.8 62.9 66.2 67.7 67.3 67.0

Population, ages 65 and above (% of total) 9.7 11.3 13.4 16.2 17.1 17.8

Population density (people per km2) 94.37 106.18 108.49 111.18 114.66 113.90a

Population growth (annual %) !0.35 1.05 !0.26 0.62 0.40 0.10

Population, female (% of total) 52.4 51.9 51.8 51.7 51.6 51.6

Population, total (000s) 8 681 9 766 9 983 10 223 10 549 10 633

Urban population (% of total) 38.8 42.8 47.9 54.4 57.6 58.2b

Proportion of single-person households (%) – – 4.0 5.5 – –

Educational level – 9 years of school (%) 14.4 25.8 54.0 83.9 82.5 86.5c

Sources : Data from INE; United Nations, 2009; World Bank, 2009; CIA, 2011.Notes : a2008; b2006; c2007.

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1.2 Economic context

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Table 1.2Macroeconomic indicators, latest available year

Year

GDP (constant LCU) (million €) 163 051.6 2009

GDP per capita, PPP (constant 2000 international $) 18 000 2004

GDP per capita (constant LCU) 12 421 2008

GDP, PPP (constant 2000 international $, in billions) 189 2004

GDP growth (last 10 years average %) 1.16 2009

GINI Index 38.5 2007

Overall general government balance, excluding temporary measures (%GDP) !9.3 2009

Agriculture, value added (% of GDP) 3 2007

Industry, value added (% of GDP) 24 2007

Manufacturing, value added (% of GDP) 73 2007

Current account balance (% of GDP) !7.6 2009

Labour force, total 5 582 700 2009

Unemployment, total (% of total labour force) 9.5 2009

Official exchange rate (US$, €, period average) 1.39 2009

Nominal short-run interest rate (%) 1.2 2009

Nominal long-run interest rate (%) 4.3 2009

Inflation rate !0.8 2009

Sources : Government of the Republic of Portugal, 2009; World Bank, 2009; INE, 2009e; Portuguese Central Bank, 2009.Notes : LCU: Local currency unit; PPP: Purchasing power parity.

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Health systems in transition Portugal6

1.3 Political context

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1.4 Health status

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Table 1.3Mortality and health indicators, 1970–2008 (selected years)

1970 1980 1990 2000 2007 2008

Life expectancy at birth, female (years) 70.3 74.6 77.6 80.3 81.6 81.4

Life expectancy at birth, male (years) 64.0 67.5 70.6 73.2 74.9 74.9

Life expectancy at birth, total (years) 67.1 71.2 74.1 76.8 78.3 78.2

Mortality rate (per 1 000 female adults) 10.1 9.0 9.6 9.5 9.2 9.3

Mortality rate (per 1 000 male adults) 11.5 10.6 11.1 11.1 10.4 10.4

Mortality rate, crude (per 1 000) 10.7 9.7 10.3 10.3 9.8 9.8

Infant deaths per 1 000 live births 55.5 24.3 10.9 5.5 3.4 3.3

Probability of dying before age 5 years (per 1 000 live births) – 29.2 14.0 7.3 4.2 4.0

Sources : INE, 2009a, 2009b, 2009c, 2009e; WHO Regional Office for Europe, 2010.

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Health systems in transition Portugal8

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Table 1.4Maternal and child health indicators, 1970–2009 (selected years)

1970 1980 1990 2000 2008 2009

Perinatal mortality rate (per 1 000 live births)a – 23.8 12.4 6.4 4.4 4.6

Neonatal mortality rate (per 1 000 live births)a – 15.4 6.9 3.4 2.1 2.5

Fertility indexb 3.0 2.3 1.6 1.6 1.4 1.4

Maternal death (per 100 000 live births)c 73.4 19.0 10.3 2.5 3.8 3.8

Adolescent pregnancy rates (age<20) (per 100 live births)b – – – – 4.2 4.2

Sources : a INE, 2009g; b INE, 2009a; c INE, 2009f, 2009g.

Table 1.5Infant mortality rates (per 1 000 live births) by region, 2000–2008 (selected years)

2000 2004 2005 2006 2007 2008

Continent 5.3 3.8 3.4 3.3 3.4 3.3

North 5.8 4.0 3.8 3.1 3.5 3.6

Centre 4.5 3.2 2.8 3.0 2.8 2.6

Lisbon 5.0 3.9 3.3 3.4 3.5 3.7

Alentejo 5.3 3.4 3.5 3.1 3.7 3.8

Algarve 5.5 4.2 3.6 5.0 3.9 3.2

Source : ACS–Ministry of Health, 2009.

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Health systems in transition Portugal10

Table 1.6Main causes of death – percentage of total number of deaths, 1990–2009 (selected years)

1990 1995 2000 2005 2006 2007 2008 2009

Diseases of the circulatory system 44.2 41.9 38.7 34.0 32.2 32.9 32.3 31.9

Malignant neoplasms 17.7 19.3 20.3 21.1 21.7 22.6 23.0 23.2

Diseases of the respiratory system 7.3 7.7 9.7 10.5 11.3 10.6 11.1 11.7

Diseases of the digestive system 4.5 4.4 3.9 4.3 4.2 4.4 4.4 4.4

Diabetes mellitus 2.6 3.0 3.0 4.3 3.7 4.2 4.1 4.4

Source : INE, 2009g.

Table 1.7Main causes of death (standardized mortality ratea per 100 000 population), 2005–2008

2005 2006 2007 2008

Diseases of the circulatory system 211.7 186.5 187.6 181.2

Cerebrovascular diseases 92.5 80.7 80.8 77.1

Ischaemic heart disease 52.6 46.1 46.8 44.0

Malignant neoplasms 155.7 149.7 154.6 155.4

Stomach 16.5 15.1 15.4 16.1

Lung 22.9 23.8 23.1 23.3

Breast 19.9 20.1 18.9 19.8

Prostate 23.3 23.4 22.8 23.1

Diseases of the respiratory system 64.3 63.9 58.9 60.4

Diseases of the digestive system 31.8 29.1 30.2 29.4

Diabetes mellitus 27.2 21.5 24.8 23.5

Land transport accidents 11.7 9.1 9.3 8.5

External cause of deathb 35.7 35.2 33.2 33.2

Total 673.9 629.3 623.1 613.0

Source : INE, 2009g.Notes : a The standardized mortality rate is computed for all ages based on the standardized European population; b Currently a DGH project is under way to improve information on causes of death, which should improve accuracy. Future data may show a detailed picture of the main causes of death in Portugal.

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Health systems in transition Portugal 11

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Table 1.8DALE (years), 1999–2002

1999 2000 2001 2002

Countries MF M F MF M F MF M F MF M F

Portugal 69 66 73 67 64 69 67 64 69 69 67 72

Spain 73 70 76 71 69 63 71 69 73 73 70 76

United Kingdom 72 70 74 69 68 70 70 68 70 71 69 72

EU15 72 – – 70 – – 70 – – 72 – –

Source : WHO Regional Office for Europe, 2010.

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Health systems in transition Portugal12

Table 1.9WHO Health for All immunization categories (percentage of children under 3 years), 2008

Category %

Infants vaccinated against

TB 98.3

Diphtheria 96.8

Tetanus 96.8

Pertussis 96.8

Poliomyelitis 96.9

Hepatitis B 96.8

Rubella 96.6

Children vaccinated against measles 96.6

Infants vaccinated against invasive disease due to haemophilius influenza type B 96.8

Source : WHO Regional Office for Europe, 2010.

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Health systems in transition Portugal 13

Fig. 1.1 Levels of immunization for measles in the WHO European Region (%), 2009 or latest available year

Source : WHO Regional Office for Europe, 2011.Notes : CIS: Commonwealth of Independent States; CARK: Central Asian republics and Kazakhstan.

0 20 40 60 80 100Austria

MaltaGeorgia

DenmarkMontenegro

United KingdomSwitzerlandItaly (2006)

CyprusTajikistan

FranceIreland

Republic of MoldovaEU members before May 2004

EUR-ANorway

IsraelIceland

San MarinoEU

Bosnia and HerzegovinaBelgium

Ukraine (2008)WHO European Region

SloveniaSerbia

PortugalEstonia

UzbekistanCroatia (2008)

LatviaThe former Yugoslav Republic of Macedonia

GermanyLithuaniaArmeniaBulgaria

NetherlandsLuxembourg

CARKSweden

Czech Republic (2004)CIS

TurkeyAlbania

EUR-B+CRomania (2007)

SpainEU members since 2004 or 2007

AndorraPoland

AzerbaijanRussian Federation

FinlandBelarus

KyrgyzstanGreece

SlovakiaMonaco (2004)

KazakhstanTurkmenistan

Hungary 99.899.4 99.0 99.0 99.0

98.7 98.7

98.6 98.3 98.3 97.54 98 97.8 97.8 97.3 97.1 96.93 97 97 96.9 96.6 96.6 96.5 96.296.2 96.2 96.096.0

95.595.9

95.4

95.0

95.0

97.5 97.1 97.0 97.0 97.0 96.9 96.9 96.7 96.2 96.2 96.2 96.1 96.0 96.0 95.9 95.8 95.7

95.0 95.0

95.595.4

95.0 95.095.0 94.4994.5 94.3 94.0 93.0 92.9 92.9

92.0 92.0 92.0

91.3

91.891.7

90.4 90.1

89.2 87.0 87.0 87.0

86.0 85.9

84.0 82.7

98.5 98.7 98.7 98.8 98.7 98.7 98.9 98.7 98.7 98.9

98.7 98.7 98.5 98.3 98.3 98.0 97.5

82.0 76.076.0

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Health systems in transition Portugal14

FDUH�DFFHVV�DQG�TXDOLW\��7KHVH�IDFWRUV�DUH�PRVW�OLNHO\�GXH�WR�WKH�HYROXWLRQ�RI�WKH�SULPDU\�DQG�ORQJ�WHUP�FDUH�QHWZRUNV��DV�ZHOO�DV�WKH�UHFHQW�HQIRUFHPHQW�RI�WKH�1DWLRQDO�+HDOWK�3ODQ��&KDSWHU���SUHVHQWV�WKH�UHVXOWV�RI�D�SURVSHFWLYH�DQDO\VLV�RI�3RUWXJXHVH�KHDOWK�VWDWXV��

Table 1.10Major factors affecting health status, 2001 and 2006

2001 2006

M F M F

Youth

Tobacco – % of individuals who smoke daily (15–24 years) 25.7 10.6 25.9 14.2

Alcohol – % of individuals who consumed alcohol in the last 12 months (15–24 years)

48.7 25.5 50.1 35.2

Weight – % of individuals with body mass index between 27 and 29.9 (18–24 years)

6.6 4.5 9.4 6.0

Obesity – % of individuals with body mass index *30 (18–24 years) 3.0 2.3 4.2 3.4

Adults

Tobacco – % of smoking individuals (25–44 years) 45.6 17.3 37.6 17.5

Tobacco – % of smoking individuals (45–64 years) 26.8 4.5 25.5 8.4

Alcohol – % of individuals who consumed alcohol in the last 12 months (25–44 years)

86.0 54.1 82.0 54.0

Alcohol – % of individuals who consumed alcohol in the last 12 months (45–64 years)

87.8 48.6 89.2 57.6

Weight – % of individuals with body mass index between 27 and 29.9 (35–44 years)

22.1 16.3 19.8 14.4

Weight – % of individuals with body mass index between 27 and 29.9 (55–64 years)

25.5 22.1 25.4 25.3

Obesity – % of individuals with body mass index *30 (35–44 years) 11.3 11.6 12.8 12.7

Older adults

Tobacco – % of smoking individuals (65–74 years) 14.4 0.9 12.1 1.3

Alcohol – % of individuals who consumed alcohol in the last 12 months (65–74 years)

78.6 38.7 81.7 43.7

Weight – % of individuals with body mass index between 27 and 29.9 (65–74 years)

26.3 21.6 26.4 22.3

Obesity – % of individuals with body mass index *30 (55–64 years) 16.2 20.3 22.0 24.3

Obesity – % of individuals with body mass index *30 (65–74 years) 14.5 19.5 19.6 23.5

Source : ACS–Ministry of Health, 2009.

Table 1.11Oral health, 2002–2006

2002/2003 2004/2005 2005/2006

Decayed, missing or filled teeth (DMFT) at age 12 (%) 3.0 1.5 1.5

Young people in need of dental treatment at age 12 (%) 18.0 43.0 44.0

6-year-old children with no dental decay (%) 33.0 50.0 51.0

Source : ACS–Ministry of Health, 2009.

Page 35: Portugal HiT (2011) _ Health System Review

2. Org

anization an

d govern

ance

2. Organization and governance

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Health systems in transition Portugal16

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2.1 Overview of the health system

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Fig. 2.1Overview chart of the health system

Direct and indirecttaxes (compulsory,

income-basedcontributions)

Payrollcontributions

Direct financing

Capital expenditure

Capital expenditureand salary + other payments

Conventioned sectorService flow

User charges

OOP payments

Reimbursementof non-NHS users

Regulated prices

DRG-basedpricing system

Agreement paymentsFee-for-service

Voluntaryrisk-ratedpremiums

Historical andactivity-based budget

Opting-out payments forsome subsystem users

Centralgovernment

Healthsubsystems

Pharmacies

Familyhealthunits

(USFs)

Healthcentres(public)

Publichospitals

Privatehospitals

Privateambulatory

care

Privateinsurance

funds

Populationand

companies

Patients

Ministryof Health

RHAs(public

insurers)

Moving towardsprospectivepaymentestablished byyearly negotiatedcontracts

Contract-based payments or fee-for-serviceService flow

Direct or prospective paymentsRetrospective payments

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Health systems in transition Portugal 17

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2.2 Historical background

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Health systems in transition Portugal18

Table 2.1The health care system: historical background and recent reform trends – timeline

1901 The first act of public health legislation was published, whereby a network of medical officers responsible for public health was created. It followed the international trend set by several institutions, which tried to develop the basis of the public health movement. This is thought to be the root of “modern sanitarism” (Ricardo Jorge reform).

1940 The first (specific) Health Department within the Ministry of Internal Affairs was established.

1944 The Social Services Statute was published, comprising a “minimum state intervention” principle in the social arena.

1945 Public maternity and child welfare services were established. Vertically organized national institutes and programmes for TB, leprosy and mental health, which were already operating, were also legally established.

1946 The law was passed that laid the groundwork for hospital organization and the promotion of new hospital buildings, financed by government funds, but run by Misericórdias. Hospital regionalization was initiated. Hospitals were to reorganize into three levels, namely municipality, district and region, ensuring technical cooperation among them.

A mandatory social health insurance system for a limited number of professions was created: the Caixas de Previdência.

1958 The Ministry of Health and Assistance was created.

1963 Statute of Health and Assistance, according to which the state is obliged to co-finance the installation and functioning of health facilities.

1968 The Hospitals Regulatory Act defined the nature and attributions of hospital care.

1971 The state was acknowledged to be responsible for health policy and implementation, for the integration of health activities, and for investment in disease prevention and health promotion. Citizens’ right to health was also recognized. Primary care centres were created.

1974 The democratic revolution occurred on 25 April, which ended a long period of right-wing political dictatorship. As a result, health services administration was taken from private holders that had been financed mainly by public funds, aiming to give the whole population access to health care, irrespective of ability to pay.

1976 The Portuguese Constitution was approved, which embodied citizens’ right to health care. It recognizes citizens’ right to health care by “the creation of a universal, free-of-charge National Health System”.

1979 The NHS Law created a universal health system, free at the point of use.

1982 The career of general practitioners (GPs)/family doctors was created.

1988 The Law on Hospital Management established guiding principles for NHS hospitals, including entrepreneurial management, decentralization of decision-making through intermediate responsibility centres and nomination of management boards by the government.

1989 The first pricing list based on DRGs was issued for third-party payers with respect to NHS hospital inpatient use by their beneficiaries. The Portuguese Constitution was reviewed, and now states that the “National Health Service is universal and tends to be free of charge, taking into account citizens’ social and economic conditions”.

1990 The Law on the Fundamental Principles of Health introduced new principles for the organization and functioning of the health system. Inter alia, an explicit role was assigned to the private profit-making and non-profit-making sectors through contracting with the NHS; the system’s operation and management was decentralized to the regional level and user charges were introduced for ambulatory services.

Private practice was allowed in public hospitals, under certain conditions related to the seniority and position of physicians as well as to the status of exclusive employment in the NHS. Private financing of health care was allowed, and incentives for private health insurance were given. The possibility of creating an alternative health insurance system was also approved.

1993 The Statute of the NHS was published in order to accommodate the changes introduced by the Law of Fundamental Principles of Health in 1990, namely the decentralization of the health system, the integration of primary care centres and hospitals in health units and the contracting out of NHS services.

The new internal organization of the Ministry of Health was published. A Decree on the statutory regulation of private health entities was issued in order to ensure the accomplishment of quality standards. Five RHAs (Administração Regional de Saúde) were established.

1995 The first attempt at putting an NHS hospital under the management control of a private consortium was initiated with the launch of a public bid for proposals according to a set of predefined terms.

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Health systems in transition Portugal 19

1997 Contracting agencies (initially named accompanying agencies) were created – one in each RHA – with the overall aim of providing the basis for the payment and provider split within the NHS. The contracting agencies should also promote means of citizens’ participation in health decision-making.

1998 An experimental payment system for GPs working at primary care centres was introduced. The intention was to pay according to capitation and performance, instead of the traditional payment by fixed salary. Enrolment in this experimental system was voluntary.

The National List of Health Equipment was published for the first time. A law on the principles of mental health policy was published, whereby community care is given priority over institutional care under different arrangements. The law also regulated the compulsory inpatient status of individuals with mental illness.

1999 The National Health Strategy and goals for the period 1998–2002, involving a broad range of social partners, was published as a revised version of an internal document issued in 1998. Legislation was passed creating local health systems and reforming primary care centres. Local health systems were integrated into frameworks for hospitals, primary care centres and other health care provider entities. Primary health care reform was based on financially autonomous primary care centres, with networks of primary health care teams. This legislation was not implemented.

The Local Health Unit of Matosinhos became the first example of effective integration of local hospitals and related primary care centres into a unique provider entity. A law was approved in Parliament to fund a special programme to reduce waiting lists for surgical procedures at NHS hospitals. The contracting out of non-NHS entities was allowed only after internal capacity was fully used. Responsibility Centres in hospitals were set up as a means of establishing intermediate management levels and promoting decentralization of authority and of responsibility, in order to achieve higher levels of efficiency in the NHS.

2000 The use of an NHS Identity Card became mandatory.

2001 Regulations for the licensing and evaluation of private clinics and dentists’ private practices were published.

2002 A framework for the implementation of PPPs for the building, maintenance and operation of health facilities was created, along with the identification of the basic principles and instruments. A new law on the management of hospitals was issued to enable the changeover of some institutions into public enterprises. A total of 34 hospitals, corresponding to approximately 40% of all NHS hospitals, were transformed into public enterprises.

A Decree established NHS drugs prescription using the common international denomination (International Nonproprietary Name, INN) as obligatory, as well as the conditions under which prescribed brands can be substituted by generics when dispensing. Reference prices for pharmaceuticals were introduced to cap state co-payment levels.

2003 The Health Regulatory Agency (HRA) was created to ensure that citizens have access to health care and to guarantee competition among health care providers.

2004 The National Health Plan for 2004–2010 was approved.

2005 A law was passed allowing the selling of over-the-counter (OTC) products in other authorized establishments (i.e. outside pharmacies).

The number of hospitals transformed into public enterprises was increased. A new legal statute was adopted to signal that there was no intention of privatization.

2006 Family health units (USFs) were created. The goal is to bring GPs closer to patients. The GP payment system depends on their performance and on the case-mix of their patients.

2007 The values of co-payments were updated. Co-payment was expanded to ambulatory surgery and hospital admission. The prices of pharmaceutical products decreased for the second consecutive year, by administrative ruling. A major restructuring of the Ministry of Health is under way.

2008 The Charter of patients’ rights to access health care was published. An administrative ruling lowers the maximum price of generic drugs.

2009 The Ministry of Health approved the National Strategy on Quality in Health Care. Hospitals are allowed to host pharmacies (other than the hospital pharmaceutical department). The co-payment on inpatient admissions is abolished.

2010 The Ministry of Health set the new paediatric age at up to 18 years old. All the hospitals are forced to present a plan to reduce expenses, due to the economic crisis in the country. The shortage of physicians leads to the hiring of retired physicians by the Ministry of Health. The prescription of unit dose pharmaceuticals is approved. The Ministry of Health nominates the Group for the Primary Health Care Reform, together with the new governance model for the reform.

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Health systems in transition Portugal20

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2.3 Organizational overview

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2.3.1 Ministry of Health

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Health systems in transition Portugal24

Fig. 2.2Organizational chart of the Ministry of Health

Note : Dotted lines represent some degree of independence from the Ministry of Health.

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Ministerof Health

Health Secretaryof State

Adjunct HealthSecretary of State

National HealthCouncil (CNS)

Health RegulatoryAgency (HRA)

Directadministration

High Commissariatfor Health (ACS)

General Inspectorate ofHealth-related Activities

(IGAS)

Directorate-Generalof Health (DGH)

Authority for Bloodand Transplantation

Services (ASST)

General Secretariatof Health (SG)

Central Administrationof the

Health System (ACSS)

PortugueseBlood Institute (IPS)

Regional healthadministrations (RHAs)

National Institute ofDrug Addiction (IDT)

National Authorityof Medicines andHealth Products

(INFARMED)

National Institutefor Medical

Emergencies (INEM)

Long-termintegrated care

Partnershipson health

National Instituteof Health

Dr Ricardo Jorge(INSA)

Indirectadministration

Missionstructures

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Health systems in transition Portugal 25

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2.3.2 Ministry of Finance

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2.3.4 Ministry of Science and Higher Education

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2.3.7 Misericórdias

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Health systems in transition Portugal 31

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2.3.8 Private health insurance companies

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2.3.9 Professional associations and unions

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2.3.10 Patient groups

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2.4 Decentralization and centralization

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2.5 Planning

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Health systems in transition Portugal 35

2.6 Health information management

2.6.1 Information systems

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2.6.2 HTA

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Health systems in transition Portugal 39

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2.7.1 Regulation and governance of third-party payers

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2.7.2 Regulation and governance of providers

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Health systems in transition Portugal 43

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2.7.4 Regulation and governance of pharmaceutical care

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Health systems in transition Portugal 45

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2.7.5 Regulation and governance of medical devices

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Health systems in transition Portugal46

2.7.6 Regulation of capital investment

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2.8 Patient empowerment

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2.8.1 Patient information

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2.8.2 Patient choice

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2.8.3 Patient rights

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Health systems in transition Portugal48

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2.8.4 Complaints procedures

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Health systems in transition Portugal 49

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2.8.5 Public participation

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Health systems in transition Portugal50

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2.8.6 Patients and cross-border care

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3. Financing

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Health systems in transition Portugal52

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3.1 Health expenditure

7DEOH�����VKRZV�WKH�SHUFHQWDJH�RI�WRWDO�KHDOWK�H[SHQGLWXUH�ILQDQFHG�WKURXJK�SXEOLF�DQG�SULYDWH�VRXUFHV��3XEOLF�H[SHQGLWXUH��ZKLFK�FRPHV�PDLQO\�IURP�WD[DWLRQ��RYHU�������LQFOXGHV�IXQGLQJ�RI�GLUHFW�FDUH�SURYLVLRQ�ZLWKLQ�WKH�1+6�DQG�VXEVLGLHV�WR�WKH�KHDOWK�VXEV\VWHPV�IRU�SXEOLF�VHFWRU�HPSOR\HHV��3ULYDWH�H[SHQGLWXUH�PDLQO\�LQFOXGHV�223�SD\PHQWV�DQG�9+,���6HH�)LJ������IRU�D�EURDG�SLFWXUH�RI�WKH�ILQDQFLDO�IORZV��

Table 3.1Trends in health expenditure, 2000 to latest available year

2000 2005 2006 2007 2008

Total health expenditure in € per capita 1 012.0 1 367.4 1 394.6 1 440.5 –

Total health expenditure as % of GDP 8.5 9.7 9.5 9.4 –

Public expenditure on health as % of total health expenditure 72.9 71.4 71.2 69.8 –

Private expenditure on health as % of total health expenditure 27.1 28.6 28.8 30.2 –

Mean annual real growth rate in GDP (base: 2000) 3.95 0.94 1.40 1.87 !0.02

Total government spending as % of GDP 41.9 45.1 46.3 45.8 46.1

Government health spending as % of total government spending 12.7 10.5 9.95 6.87 7.06

Government health spending as % of GDP 4.3 6.3 5.9 5.5 5.5

OOP payments as % of total health expenditure 23.2 23.9 23.1 – –

Sources : INE, 2010; Ministry of Finance & Ministry of Internal Affairs, 2000–2008. Note : Data are also available at http://www.pordata.pt/.

223�SD\PHQWV�LQ�3RUWXJDO�DUH�HVWLPDWHG�WR�EH�DPRQJ�WKH�KLJKHVW�LQ�(XURSH��7KH\�DFFRXQWHG�IRU�DSSUR[LPDWHO\�������RI�WRWDO�KHDOWK�H[SHQGLWXUH�LQ������DQG�KDYH�EHHQ�VOLJKWO\�DERYH�����VLQFH�������VHH�VHFWLRQ�������)ROORZLQJ�WKH�FRQFOXVLRQV�RI�LQWHUQDWLRQDO�VWXGLHV��VHH�:DJVWDII�HW�DO����������RQH�PD\�VWDWH�WKDW��RYHUDOO��WKH�WKHRUHWLFDOO\�SURJUHVVLYH�UHGLVWULEXWLYH�LQFRPH�WD[�V\VWHP�LQ�3RUWXJDO�WXUQV�RXW�WR�EH�VOLJKWO\�UHJUHVVLYH�LQ�KHDOWK�FDUH�ILQDQFLQJ�GXH�WR�D�KLJK�VKDUH�RI�223�SD\PHQWV�DORQJ�ZLWK�D�KHDY\�UHOLDQFH�RQ�LQGLUHFW�WD[HV��,QGLUHFW�WD[HV�RQ�JRRGV�DQG�VHUYLFHV�DFFRXQW�IRU�������RI�WRWDO�JRYHUQPHQW�UHYHQXH�LQ�������7KH�H[LVWHQFH�RI�D�JHQHURXV��E\�LQWHUQDWLRQDO�VWDQGDUGV��V\VWHP�RI�WD[�EHQHILWV�WR�SULYDWH�KHDOWK�VSHQGLQJ�DGGV�WR�WKLV�UHJUHVVLYLW\�RI�KHDOWK�FDUH�IXQGLQJ��,Q�RWKHU�ZRUGV��KHDOWK�H[SHQGLWXUH�IDOOV�UHODWLYHO\�PRUH�KHDYLO\�RQ�ORZ�LQFRPH�

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Health systems in transition Portugal 53

Fig. 3.1Financial flows

KRXVHKROGV��7KHVH�FRQWULEXWRUV�DUH�OHVV�DEOH�WR�REWDLQ�D�KLJKHU�SHUFHQWDJH�UHIXQG�IURP�WKH�WD[�V\VWHP�WKDQ�WKH�KLJK�LQFRPH�KRXVHKROGV�����YHUVXV������ZKHQ�DQDO\VLQJ�WKH�ORZHU�DQG�XSSHU�JURXSV�RI�WKH�LQFRPH�GLVWULEXWLRQ��

'DWD�SUHVHQWHG�KHUH�RULJLQDWH�IURP�WKH�UHFHQWO\�SXEOLVKHG�1DWLRQDO�+HDOWK�$FFRXQWV��,1(���������FRQVWUXFWHG�LQ�DFFRUGDQFH�ZLWK�:+2�2(&'�SULQFLSOHV�DQG�IURP�WKH�:+2�+HDOWK�IRU�$OO�'DWDEDVH��:+2�5HJLRQDO�2IILFH�IRU�(XURSH���������7RWDO�KHDOWK�FDUH�H[SHQGLWXUH�LQ�3RUWXJDO�KDV�ULVHQ�VWHDGLO\�IURP�DV�OLWWOH�DV����LQ������WR�DOPRVW�����RI�*'3�LQ�������,Q�������KHDOWK�VSHQGLQJ�PDGH�XS�����RI�*'3�LQ�3RUWXJDO��DERYH�WKH�(8���DYHUDJH�RI�����VHH�)LJ��������3RUWXJDO�QRZ�VSHQGV�PRUH�WKDQ�ERWK�,WDO\�DQG�6SDLQ�LQ�WHUPV�RI�SURSRUWLRQ�RI�

Population

Patients

Central government Ministry of Health

Health subsystems

Private insurance funds

RHAs

RHAContracting Agency

Pharmacists

Private clinics/hospitals and

services

Health professionalspublic and

private practices

Primary carecentres

Publichospitals

Contract-based paymentsService flow

Direct or prospective paymentsRetrospective payments

Capitalexpenditure

Salary +other payments

Capitalexpenditure

OOP

paym

ent

Dire

ct a

nd in

dire

ct ta

xes

Volu

ntar

y ris

k-ra

ted

prem

ium

s

Retro

spec

tive

reim

burs

emen

t

Payroll contributionsFee for serviceor per diem

Fee for serviceor per diem

Opting-out

Directfinancing Contract

payment

Contractpayment

Historical andactivity costs budget

ACSS

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Health systems in transition Portugal54

Fig. 3.2Health expenditure as a share (%) of GDP in the WHO European Region, 2008

Source : WHO Regional Office for Europe, 2011.Notes : CIS: Commonwealth of Independent States; CARK: Central Asian republics and Kazakhstan.

0 2 4 6 8 10 12 14CARK

CISEur-B+C

EU members since 2004 or 2007WHO European Region

EUEur-A

EU members before May 2004Averages

TurkmenistanAzerbaijan

KazakhstanArmenia

UzbekistanRussian Federation

TajikistanBelarus

KyrgyzstanUkraineGeorgia

Republic of MoldovaCIS

RomaniaEstonia

LithuaniaLatvia

PolandCzech Republic

AlbaniaTFYR Macedonia

BulgariaHungarySlovakiaCroatia

SloveniaMontenegro

SerbiaBosnia and Herzegovina

Central and south-eastern EuropeMonaco

TurkeyCyprus

San MarinoLuxembourg

AndorraMaltaIsrael

FinlandNorwayIrelandSpain

United KingdomItaly

SwedenNetherlands

BelgiumGreece

DenmarkAustria

PortugalGermany

SwitzerlandFranceIceland

10.4

11.110.5

10.1 10.1

9.9

11.8

9.7

7.5

9.8

11.8

9.7 9.7 9.7

9.1 9.1

9.0 9.0

8.78.7

8.68.4

8.07.57.5 7.5

7.27.1

6.75.0

10.3

10.78.7

6.86.6

6.5

5.05.2

4.0

9.69

5.6

9.8 9.5 9.5

7.8 7.8 7.8 7.8 7.8 7.8

7.4 7.4 7.3

7.0 6.9

6.8 6.6

6.5 6.2

5.9 4.7

9.7

5.68 5.7 5.44 5.4

7.56 7.6

9.56 9.6

5.6

3.83.83.73.7

3.63.61.81.8

9.0

4.6

6.4

Western Europe

Page 75: Portugal HiT (2011) _ Health System Review

Health systems in transition Portugal 55

*'3��)LJ��������GHVSLWH�KDYLQJ�VSHQW�FRQVLGHUDEO\�OHVV�WKDQ�WKH\�GLG�LQ�������3RUWXJDO�VSHQGV�DERYH�86�������SHU�FDSLWD��ZKLFK�LV�VOLJKWO\�EHORZ�WKH�(8���DYHUDJH��)LJ��������GHVSLWH�VSHQGLQJ�DOPRVW�WKH�KLJKHVW�DPRXQW�RQ�KHDOWK�FDUH�DV�D�SURSRUWLRQ�RI�*'3�

Fig. 3.3Trends in health expenditure as a share (%) of GDP in Portugal and selected countries, 1995–2008

Source : WHO Regional Office for Europe, 2011.

$V�VKRZQ�LQ�7DEOH������S�������WKH�DPRXQW�VSHQW�RQ�KHDOWK�FDUH�KDV�LQFUHDVHG�LQ�ERWK�DEVROXWH�DQG�UHODWLYH�WHUPV��*URZWK�UDWHV�RI�WRWDO�KHDOWK�H[SHQGLWXUH�VHHP�WR�EH�VORZLQJ�GRZQ��DV�ZHOO�DV�*'3�UDWHV��WKRXJK�WKH\�VWLOO�VKRZ�D�VWHDG\�DQG�VWURQJ�JURZWK�SDWWHUQ��DQG�WKH�SURSRUWLRQ�RI�WRWDO�KHDOWK�H[SHQGLWXUH�RYHU�*'3�KDV�DOVR�LQFUHDVHG��7KH�JURZWK�LQ�WRWDO�KHDOWK�H[SHQGLWXUH�ZDV�PRUH�SURQRXQFHG�LQ�SXEOLF�KHDOWK�H[SHQGLWXUH��ZKLFK�VWHDGLO\�LQFUHDVHG�LWV�VKDUH�RI�H[SHQVHV��'HVSLWH�WKH�LQFUHDVH��SXEOLF�VRXUFHV�RI�VSHQGLQJ�DV�D�SURSRUWLRQ�RI�WRWDO�KHDOWK�H[SHQGLWXUH�DUH�WKH�ORZHVW�DPRQJ�WKH�(8���FRXQWULHV��)LJ��������,W�DSSHDUV�WKDW�3RUWXJDO�KDV�QRW�FRQWDLQHG�KHDOWK�H[SHQGLWXUH�JURZWK�DV�VXFFHVVIXOO\�DV�RWKHU�VRXWKHUQ�(XURSHDQ�FRXQWULHV��2QH�SODXVLEOH�H[SODQDWLRQ�OLHV�LQ�WKH�FRXQWU\¶V�SROLWLFDO�UHOXFWDQFH�WR�LPSRVH�FRVW�FRQWURO�PHDVXUHV�DIWHU�LW�ZDV�DVVXPHG�WKDW�LQYHVWPHQW�ZDV�QHHGHG�LQ�RUGHU�WR�EXLOG�XS�QHZ�IDFLOLWLHV�DQG�WR�SURPRWH�WKH�H[SDQVLRQ�RI�1+6�FRYHUDJH��'L[RQ��0RVVLDORV��������

6

7

8

9

10

11

12

United KingdomSpain

Portugal

Italy

France

20082007200620052004200320022001200019991998199719961995

%

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Health systems in transition Portugal56

Fig. 3.4Health expenditure in US$ PPP per capita in the WHO European Region, 2008

Source : WHO Regional Office for Europe, 2011.Notes : PPP: Purchasing power parity; CIS: Commonwealth of Independent States; CARK: Central Asian republics and Kazakhstan.

0 1000 2000 3000 4000 5000 6000 7000CARK

CISEur-B+C

EU members since 2004 or 2007WHO European Region

EUEur-A

EU members before May 2004AveragesTajikistan

TurkmenistanUzbekistanKyrgyzstan

ArmeniaAzerbaijan

Republic of MoldovaKazakhstan

GeorgiaUkraineBelarus

Russian FederationCIS

AlbaniaRomania

The former Yugoslav Republic of MacedoniaSerbia

Bosnia and HerzegovinaBulgaria

LatviaPoland

LithuaniaEstonia

MontenegroHungary

CroatiaCzech Republic

SlovakiaSlovenia

Central and south-eastern EuropeTurkeyIsrael

PortugalMonaco

SpainItaly

GreeceSan Marino

FinlandAndorra

United KingdomCyprus

BelgiumSweden

DenmarkIreland

GermanyNetherlands

FranceAustria

MaltaIceland

SwitzerlandNorway

Luxembourg

4 310

4 989

2 334

3 749

2 852

6 047

3 749 3 692 3 692 3 676 3 676

3 630 3 630 3 423 3 392

3 3123 2303 191

2 9792 962

2 852

2 791 2 791

695 695

2 559 2 559

4 620

3 836

2 825 2 825

4 039

2 288

2 183

318316

498432420

161228

2 877.46

4 620

1 717

867 867

1 496

838 838 702 702

665 665

1 419

866 866800 800

1 319 1 226

1 178 1 1621 112

910

543

2 878

620.25 620 206

729.43 729

1 969

3 3203 281

1 195

120 107

134

Western Europe

3 8363 7783 778

1 717 1 684 1 684

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Health systems in transition Portugal 57

Fig. 3.5Public sector health expenditure as a share (%) of total health expenditure in the WHO European Region, 2008

Source : WHO Regional Office for Europe, 2011.Notes : CIS: Commonwealth of Independent States; CARK: Central Asian republics and Kazakhstan.

0 10 20 30 40 50 60 70 80 90 100CARK

CISEur-B+C

WHO European RegionEU members since 2004 or 2007

EUEur-A

EU members before May 2004Averages

GeorgiaAzerbaijanTajikistanArmenia

KyrgyzstanUzbekistan

Republic of MoldovaTurkmenistan

UkraineRussian Federation

KazakhstanBelarus

CISAlbania

BulgariaBosnia and Herzegovina

LatviaMontenegro

SerbiaSlovakiaHungary

The former Yugoslav Republic of MacedoniaPoland

SloveniaLithuania

EstoniaRomania

Czech RepublicCroatia

Central and south-eastern EuropeCyprus

IsraelSwitzerland

GreeceTurkey

AndorraPortugal

SpainBelgiumFinland

MonacoAustria

GermanyItaly

MaltaFranceIreland

SwedenNetherlands

United KingdomNorway

DenmarkSan Marino

IcelandLuxembourg

84.7

70.2

76.8

69.0

91.1

76.876.6 76.6

74.9 74.9 74.8 74.8

82.8 82.182.082.0

79.0

74.372.8

69.0

57.2 57.2

84.9 84.9

45.1 45.1

85.5

77.4

59.0 59.0

84.2

69.9

60.9

50.5

43.7

42.0

54.550.5

20.724.0

77.51

85.5 87.3 87.3

84.7

66.8 66.8

81.0

58.2 58.2 57.8 57.8

75.3 75.3

73.0

65.7 65.765.5 65.5

56.156.1

47.947.9

26.226.2

71.471.070.5 70.3

60.362.5

59.6

77.577.0977.176.5676.6

58.7958.851.6

69.863.0

73.0

Western Europe

77.477.477.4

84.7

78.7 78.7

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Health systems in transition Portugal58

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3.2 Sources of revenue and financial flows

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3ULYDWH�KHDOWK�H[SHQGLWXUH�KDV�ZLWQHVVHG�VRPH�JURZWK�LQ�UHFHQW�\HDUV��WKRXJK�DW�D�VORZHU�UDWH�WKDQ�SXEOLF�KHDOWK�H[SHQGLWXUH��$�ODUJH�SURSRUWLRQ�RI�ILQDQFLQJ��DERXW�����RI�WRWDO�H[SHQGLWXUH��LV�SULYDWH��PDLQO\�LQ�WKH�IRUP�RI�223�SD\PHQWV��ERWK�FR�SD\PHQWV�DQG�GLUHFW�SD\PHQWV�E\�WKH�SDWLHQW���DQG�WR�D�OHVVHU�H[WHQW�LQ�WKH�IRUP�RI�SUHPLXPV�WR�SULYDWH�LQVXUDQFH�VFKHPHV�DQG�PXWXDO�LQVWLWXWLRQV��7DEOH�����UHSRUWV�RQ�WKH�PDLQ�SULYDWH�VRXUFHV�RI�ILQDQFLQJ�LQ�WKH�SHULRG�����±������GLVWLQJXLVKLQJ�EHWZHHQ�223�SD\PHQWV��QRQ�SURILW�PDNLQJ�LQVWLWXWLRQV�VHUYLQJ�IDPLOLHV��9+,�DQG�RWKHU�SULYDWH�VRXUFHV��

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Health systems in transition Portugal 59

Table 3.2Funding mix for the health system (%), 2000–2008 (selected years)

2000 2005 2006 2007 2008

Public funding 68.8 68.9 66.9 66.6 65.6

Private funding 31.2 31.1 33.1 33.4 34.4

of which

Non-profit-making institutions serving families 0.5 0.4 0.4 0.3 0.3

VHI 11.3 14.2 14.4 14.0 15.0

OOP payments 86.4 84.1 83.9 83.9 83.4

Other private funding 1.8 1.4 1.3 1.3 1.4

Sources : INE, 2010; Ministry of Finance & Ministry of Internal Affairs (2000–2008). Note : Data are also available at http://www.pordata.pt/.

3.3 Overview of the statutory financing system

3.3.1 Coverage

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Health systems in transition Portugal60

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3.3.2 Collection

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3.3.3 Pooling of funds

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Health systems in transition Portugal62

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3.3.4 Purchasing and purchaser–provider relations

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Health systems in transition Portugal 63

3.4 OOP payments

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3.4.1 Cost-sharing

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Table 3.3User charges for health services

Health service Type of user charge Exemptions and/or reduced rates

GP visit Co-payment Social security beneficiaries and certain patient groups are exempt from these user charges

Patients over 65 years old were exempt from 50% of the inpatient user charge

Primary care Co-payment

Outpatient specialist visit Co-payment

Outpatient prescription drugs Co-insurance, varies depending on therapeutic value

Inpatient stay (Co-payment removed in 2009)

Dental care

Medical devices

Emergency visit Co-payment

Note : There is no cap on OOP payments.

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Health systems in transition Portugal64

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3.4.2 Direct payments

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3.5 VHI

3.5.1 Market role and size

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3.5.2 Market structure

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3.5.3 Market conduct

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Health systems in transition Portugal 67

3.5.4 Public policy

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3.6 Other financing

3.6.1 Parallel health systems

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Health systems in transition Portugal68

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Health systems in transition Portugal 69

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3.6.2 External sources of funds

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3.6.3 Other sources of financing

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Health systems in transition Portugal70

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3.7 Payment mechanisms

3.7.1 Paying for health services

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Health systems in transition Portugal 71

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Health systems in transition Portugal78

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4. Physical an

d human resources

4. Physical and human resources

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4.1.1 Infrastructure

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Health systems in transition Portugal80

Fig. 4.1Beds in acute hospitals per 100 000 population in Portugal and selected countries, 1990–2008

Source : WHO Regional Office for Europe, 2011.

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Table 4.1Number of beds in acute care, specialized hospitals, primary care centres and long-term care institutions in Portugal, per 100 000 population, 1995–2008 (selected years)

Hospital 1995 2000 2005 2006 2007 2008

Acute care hospitals 235.3 237.5 225.7 221.3 220.1 203.3

Specialized hospitals 52.4 42.6 32.4 30.5 28.0 24.7

Primary care centres 20.7 13.9 9.4 8.4 6.4 5.5

Long-term care network – – – – 1 788 2 870

Source : INE, 2009f.Note : Data are also available at http://www.pordata.pt/.

200

300

400

500

600

700

United KingdomSpain

PortugalItaly

France

2008200720062005200420032002200120001999199819971996199519941993199219911990

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Health systems in transition Portugal 81

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Table 4.2Operating indicators in Portugal and selected countries, 1990–2007 (selected years)

1990 1995 2000 2005 2006 2007

Portugal ALOS: inpatient care, days 10.8 9.8 9.2 8.7 8.6 8.5

ALOS: acute care, days 8.4 7.9 7.7 7.1 6.9 6.8

Acute care occupancy rate, % of available beds 66.7 72.6 71.3 73.2 71.3 72.6

Day cases, % of total surgeries performed 0.3 6.4 17.6 18.9 23.3 –

Spain ALOS: inpatient care, days 12.2 10.0 9.0 8.5 8.3 8.2

ALOS: acute care, days 9.6 8.8 7.1 6.7 6.6 6.6

Acute care occupancy rate, % of available beds 73.5 76.4 77.2 79.1 78.2 78.2

Day cases, % of total surgeries performed – 16.8 31.4 32.2 33.4 –

France ALOS: inpatient care, days 15.1 14.1 13.2 13.3 13.0 13.0

ALOS: acute care, days 7.0 6.2 5.6 5.4 5.3 5.3

Acute care occupancy rate, % of available beds 77.3 76.0 75.4 73.5 73.7 73.9

Day cases, % of total surgeries performed – – – – – –

Italy ALOS: inpatient care, days 11.7 10.1 7.7 7.4 7.5 7.5

ALOS: acute care, days 9.5 8.4 7.0 6.7 6.7 6.7

Acute care occupancy rate, % of available beds 69.3 70.7 76.0 77.3 78.0 78.8

Day cases, % of total surgeries performed – 14.8 35.9 35.8 35.1 –

United Kingdom

ALOS: inpatient care, days – – 9.9 9.1 8.8 8.2

ALOS: acute care, days – – 8.2 7.9 7.6 7.2

Acute care occupancy rate, % of available beds – 83.4 83.9 83.5 83.4 –

Day cases, % of total surgeries performed 29.1 41.9 50.6 55.8 55.4 54.4

Source : OECD, 2010.

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Health systems in transition Portugal82

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Health systems in transition Portugal 83

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Table 4.3PPPs in Portugal

Hospital de Loures II

Hospital de Cascais

Hospital de Braga

Hospital de V.F. Xira

Started 12 May 2006 13 May 2004 18 November 2004 20 April 2005

Preparation and previous evaluation

245 days 76 days 32 days 139 days

Approval and launch 66 days 40 days 30 days 88 days

Proposals 159 days 138 days 226 days 136 days

Evaluation of the proposals 404 daysa 509 days 436 days 690 days

Competitive bargaining – 171 days 380 days 132 daysa

Final bargaining – 315 days 200 daysa –

Beginning of the public–private partnership

– 8 October 2008 – –

Source : Court of Auditors, 2009.Note : a Measured on 16 October 2008.

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Health systems in transition Portugal84

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4.1.3 Medical equipment, devices and aids

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4.1.4 IT

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Health systems in transition Portugal 85

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4.2 Human resources

4.2.1 Trends in health care personnel

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Health systems in transition Portugal86

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Table 4.4Health care personnel, 1990–2008 (selected years)

1990 1995 2000 2005 2006 2007 2008

Doctors 28 016 29 353 32 498 36 183 36 924 37 904 38 932

Dentists 667 1 411 3 321 5 056 5 665 5 629 6 033

Orthodontists 375 341 293 384 374 374 374

Nurses 28 154 34 225 – 48 155 50 955 54 079 56 079

Pharmacists 5 438 – 8 056 9 494 10 091 10 117 10 729

Source : INE, 2009d. Note : Data are also available at http://www.pordata.pt/.

Fig. 4.2Number of physicians per 100 000 population in Portugal and selected countries, 1990 to latest available year

Source : WHO Regional Office for Europe, 2011.

0

100

200

300

400

500

United Kingdom

SpainPortugal

Italy

France

20092008200720062005200420032002200120001999199819971996199519941993199219911990

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Health systems in transition Portugal 87

Fig. 4.3Number of nurses per 100 000 population in Portugal and selected countries, 1990 to latest available year

Source : WHO Regional Office for Europe, 2011.

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200

300

400

500

600

700

800

900

1 000

United Kingdom

Spain

Portugal

Italy

France

20092008200720062005200420032002200120001999199819971996199519941993199219911990

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Health systems in transition Portugal88

Fig. 4.4Number of physicians and nurses per 100 000 population in the WHO European Region, 2009 or latest available year

Source : WHO Regional Office for Europe, 2011.Notes : p: physicians; n: nurses; CIS: Commonwealth of Independent States; CARK: Central Asian republics and Kazakhstan.

0 500 1 000 1 500 2 000Turkey (2008)

Belgium (2008)Albania

The former Yugoslav Republic of Macedonia (2007p, 2006n)Greece (2008)

TajikistanSerbia

Bosnia and HerzegovinaTurkmenistan

AndorraMontenegro

Poland (2008)Armenia

Cyprus (2008)San Marino (1990)

LatviaRomania (2008)

Kyrgyzstan (2007)Bulgaria (2008)Croatia (2008)

GeorgiaIsrael (2008n)

SpainEU members since 2004 or 2007 (2008)

Portugal (2008n)Malta

Hungary (2008)Slovakia (2007p, 2008n)

Estonia (2008)Slovenia (2008)

Italy (2008p)Republic of Moldova

CARKAzerbaijan

Eur-B+CLithuania (2008)

KazakhstanUkraine

WHO European Region (2008)EU (2008)

Czech Republic (2008)CIS

EU members before May 2004 (2008p, 2007n)France (2008p)

Eur-A (2008)Austria (2008n)United Kingdom

Russian Federation (2006)Uzbekistan

Luxembourg (2007p, 2006n)Netherlands (2007)

Germany (2008)Sweden (2006)

BelarusDenmark (2007)

Norway (2008)Finland (2008p, 2007n)

Ireland (2008p)Iceland (2008)

Switzerland (2008n)Monaco (1992p, 1995n)

1 480

300392

372

311272

342

358511

356

1 5361 547

1 244

400

370

1 400

1 429

1 5191 621

1 0681 083

1 051

284260

431267

468

344

377342

354

343

328

328315

381370

318

279

412

310

238

366

335

300309

304377

271

339

266467

360

354

238

221299

252287

346

207

238316

168

216

211

115

247

158

194

1 0941 040

806

859

953751

847838798

792

793792

534

784

752

711711

703788

742

640

630781

625

591

615619

493

495346

543

522424

552

468

465508

406519

512

484

355422

429

287

438601

390298

140

Physicians Nurses

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Health systems in transition Portugal 89

Fig. 4.5Number of dentists per 100 000 population in Portugal and selected countries, 1990 to latest available year

Source : WHO Regional Office for Europe, 2011.

4.2.2 Professional mobility of health workers

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Table 4.5Foreign physicians working for the NHS, 2004–2007

2004 2005 2006 2007

Total number of foreign doctors 2 113 2 123 1 990 1 903

Inpatient care 1 053 1 050 978 814

GPs 770 795 765 780

Public health 28 22 27 35

Other physicians 262 256 220 274

Source : Ministry of Health, 2010.

10

20

30

40

50

60

70

80

United Kingdom

Spain

Portugal

Italy

France

20092008200720062005200420032002200120001999199819971996199519941993199219911990

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Health systems in transition Portugal90

4.2.3 Training of health care personnel

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Health systems in transition Portugal 91

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Fig. 4.6Number of pharmacists per 100 000 population in Portugal and selected countries, 1990 to latest available year

Source : WHO Regional Office for Europe, 2011.

40

50

60

70

80

90

100

110

120

130

United Kingdom

Spain

Portugal

Italy

France

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Health systems in transition Portugal92

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Health systems in transition Portugal94

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Health systems in transition Portugal 97

5.2 Patient pathways

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Health systems in transition Portugal 99

Fig. 5.1Outpatient contacts per person per year in the WHO European Region, 2009 or latest available year

Source : WHO Regional Office for Europe, 2011.Notes : CIS: Commonwealth of Independent States; CARK: Central Asian republics and Kazakhstan.

0 3 6 9 12United Kingdom

AlbaniaGeorgia

Cyprus (2008)Malta

Sweden (2006)Luxembourg (1998)

ArmeniaKyrgyzstan (2008)

TurkmenistanNorway (1991)

Denmark (2007)Bosnia and Herzegovina

TajikistanFinland

MontenegroIceland (2005)

Portugal (2008)Azerbaijan

RomaniaGreece (1982)

Bulgaria (1999)Latvia

EU members before May 2004 (2006)Netherlands

Eur-A (2007)The former Yugoslav Republic of Macedonia (2006)

Italy (1999)EU

IsraelRepublic of Moldova

CroatiaFrance (1996)Ireland (1988)

SloveniaKazakhstan

TurkeyPoland (2008)

LithuaniaCARK

AustriaBelgium

WHO European RegionEstonia

EU members since 2004 or 2007Germany (2008)

Eur-B+CSerbia

CISUzbekistan

Russian Federation (2006)Spain (2003)

UkraineSwitzerland (1992)

HungaryCzech Republic

SlovakiaBelarus 13.1

13.03 13.0

11.0 10.7

9.5 9.0 9.0

8.61 8.5

5.85.71

8.618.5

7.91

2.46

4.75.3

7.8 7.65

7.1 7.09 7.0

6.9 6.9 6.85 6.8 6.79 6.76.62 6.6

6.5 6.366.3

6.2 6.2

6.0 6.0 5.98

5.8 5.71

5.3 5.45.4 5.65.6

4.7 4.6

4.2

4.4 4.284.2

4.5

4.19 4.15

3.8 3.6

3.5 3.44

2.8 2.8

2.462.1 2.0

1.79 0.4

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5.4.1 Referral process and links between primary and secondary care

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5.6 Pharmaceutical care

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Health systems in transition Portugal 107

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5.6.1 Pharmaceutical co-insurance

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5.6.2 Pharmaceutical expenditure and policy

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5.7 Rehabilitation/intermediate care

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5.8 Long-term care

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5.8.1 Recent developments

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Health systems in transition Portugal114

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Table 5.1Number of beds in the long-term care network, 2007–2008

2007 2008

Number of long-term care beds (RNCCI) 1 788 2 870

Rehabilitation and medium-term 646 922

Long-term 684 1 325

Palliative care 55 93

Source : Ministry of Health, 2010.

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Health systems in transition Portugal 115

5.9 Palliative care

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Health systems in transition Portugal116

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5.10 Mental health care

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Health systems in transition Portugal 117

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5.11 Dental care

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5.12 Complementary and alternative medicine

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6. Principal health care reforms

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Health systems in transition Portugal120

6.1 Analysis of recent reforms

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Table 6.1Major policy measures, 2000–2009

Policy measures Objectives

PPPs for new hospitals (2002 onwards) Improve efficiency; improve value for money in public investment

National Health Plan (2004) Health gains (priorities being cardiovascular diseases, oncological diseases and HIV/AIDS)

Preparation of the National Health Plan (2011–2016) Focus on access, quality, healthy policy and citizenship

Update in co-payments of public health care services (several years)

Moderate the consumption of health care; promote the value of NHS-funded care in the eyes of the citizens

Closure of delivery rooms in several hospitals (2006) Increase clinical quality and safety; better organization of the hospital network

Merge hospitals management team (2003 onwards) Increase efficiency (take advantage of scale and scope economies)

Provide hospitals with entrepreneurial-like status (2003 onwards)

Implement purchaser–provider split; cost-containment by better management

Contracting (2005 onwards) Implement purchaser–provider split; pay by results; cost-containment

Reductions in public cost-sharing for pharmaceutical products, administrative price reductions and reductions of margins in distribution (2005 onwards)

Cost-containment

OTC products (both price and entry liberalization) (2005) Better access to care; lower prices by increased competition

Closure of several primary care emergency services (in some cases, closure is only during the night period) (2006)

Increase clinical quality and clinical safety; better organization of the emergency care network

Primary care reform – creation of USFs (2006 onwards) and ACES (2008)

Better access; greater satisfaction for professionals and citizens; more rational use of resources, namely regarding referral decisions

Price reduction in agreements with private providers (2006, effective 2007)

Containment of public spending

RNCCI created (2006 onwards) More effective coverage; better access to care; shorter length of stay in acute care hospitals; health gains due to more efficient treatment

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6.1.1 Health promotion reforms

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6.1.2 Long-term care reforms

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6.1.3 Ambulatory care reforms

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Health systems in transition Portugal 123

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6.1.4 Inpatient care reforms

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6.1.5 Pharmaceutical reforms

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6.1.6 Regulatory reforms

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6.2 Future developments

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7. Assessm

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7. Assessment of the health system

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Health systems in transition Portugal128

7.1 Stated objectives of the health system

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7.2 Financial protection and equity in financing

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7.3 User experience and equity of access to health care

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7.4 Health outcomes, health service outcomes and quality of care

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7.5 Health system efficiency

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Health systems in transition Portugal132

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7.5.2 Technical efficiency

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8. Co

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8. Conclusions

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9. Appendices

9.1 Prospective analysis of Portuguese health status

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9.1.1 Life expectancy

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Health systems in transition Portugal138

Fig. 9.1Life expectancy at birth, 1990–2003

Source : OECD, 2009.

Fig. 9.2Life expectancy at birth – forecast, 1990–2030

Source : OECD, 2009.

72

70

1990 1995

All Population trend Men Women

2000 2005

74

76

80

78

Years

75

1990 2000

Life expectancy at birth ForecastPessimistic scenario Optimistic scenario

2010 2020 2030

80

90

85

Years

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Health systems in transition Portugal 139

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,Q�������D����\HDU�ROG�3RUWXJXHVH�PDQ�FRXOG�H[SHFW�WR�OLYH�IRU�DQRWKHU����\HDUV��%\�������WKLV�YDOXH�KDG�ULVHQ�WR������\HDUV��DQG�WKH�OLQHDU�IRUHFDVW�IRU������LQGLFDWHV�D�OLIH�H[SHFWDQF\�DW����RI������\HDUV��WKDW�LV��RQ�DYHUDJH��D����\HDU�ROG�PDQ�FRXOG�H[SHFW�WR�OLYH�XQWLO�KH�LV�����7KH�VDPH�W\SH�RI�HYROXWLRQ�RFFXUV�IRU����\HDU�ROG�ZRPHQ���,Q�6SDLQ��LQ�������D����\HDU�ROG�PDOH�FRXOG�H[SHFW�WR�OLYH�IRU�DQRWKHU������\HDUV��DQG�D�ZRPDQ¶V�OLIH�H[SHFWDQF\�DW����ZDV����\HDUV��

$�VXFFHVVIXO�1+6�FRXOG�OHDG�WR�KHDOWK�JDLQV�LQ�WHUPV�RI�OLIH�H[SHFWDQF\�DW�����,I�ZH�FDUU\�RXW�WKH�VDPH�WKRXJKW�H[SHULPHQW�DV�EHIRUH��WKHQ�D����LQFUHDVH�LQ�OLIH�H[SHFWDQF\�DW����E\������ZRXOG�OHDG�WR�DQ�DGGLWLRQDO�\HDU�LQ�OLIH�H[SHFWDQF\�DW�����IRU�ERWK�PHQ�DQG�ZRPHQ�

Fig. 9.3Life expectancy at age 65 – forecast, 1990–2030

Source : OECD, 2009.

15

1990 2000 2010 2020 2030

25

20

Years

Men Women Forecast (men) Forecast (women) Pessimistic scenario Optimistic scenario

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Health systems in transition Portugal140

9.1.2 Potential years of life lost (PYLL)

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Fig. 9.4PYLL, 1990–2003

Source : OECD, 2009.

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2 000

1990 1995 2000 2005

4 000

6 000

10 000

8 000

Population Forecast Men Women

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Health systems in transition Portugal 141

Fig. 9.5PYLL – forecast, 1990–2030

Source : OECD, 2009.

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7KH�UDWLR�RI�3<//�SHU���������LQKDELWDQWV�LQFOXGHV�DOO�FDXVHV�RI�GHDWK��+RZHYHU��WKHUH�FRXOG�EH�D�ZD\�WR�WDFNOH�VSHFLILF�FDXVHV�RI�GHDWK��DQG�FRQFHQWUDWH�WKH�HIIRUWV�RQ�GHFUHDVLQJ�SUHPDWXUH�PRUWDOLW\��$V�DQ�H[DPSOH��KHDOWK�SROLF\�FRXOG�DLP�WR�LQFUHDVH�WKH�KHDOWK�JDLQV�LQ�VRPH�LQGLFDWRUV�WKDW�DUH�NQRZQ�WR�EH�VHQVLWLYH�WR�KHDOWK�FDUH�SURPRWLRQ��3ULPDU\�SUHYHQWLRQ�ZRXOG�KHOS�SUHYHQW�PDOLJQDQW�QHRSODVPV��OXQJ��WUDFKHD�DQG�EURQFKXV���LVFKDHPLF�KHDUW�GLVHDVH��FLUUKRVLV�DQG�URDG�WUDIILF�DFFLGHQWV��0DOLJQDQW�QHRSODVPV�RI�WKH�VNLQ�DUH�XVXDOO\�WDNHQ�WR�EH�DYRLGDEOH�E\�KHDOWK�FDUH�GHOLYHU\��7KH�HYROXWLRQ�RI�PDOLJQDQW�QHRSODVPV��OXQJ�DQG�VNLQ���LVFKDHPLF�KHDUW�GLVHDVH��FLUUKRVLV�DQG�URDG�WUDIILF�DFFLGHQWV�LV�VKRZQ�LQ�)LJ������

$V�ZH�FDQ�VHH��PXFK�KDV�EHHQ�DFKLHYHG�LQ�UHGXFLQJ�3<//�GXH�WR�ODQG�WUDQVSRUW�DFFLGHQWV��+RZHYHU��RWKHU�FDXVHV�RI�GHDWK�VHHP�WR�KDYH�VWDELOL]HG�RU�HYHQ�WR�EH�JURZLQJ��)LJ��������:KDW�FDQ�ZH�VD\�DERXW�WKH�QH[W�GHFDGHV"

0

1990 2000

Population Men Women Forecast Pessimistic scenario Optimistic scenario

2010 2020 2030

4 000

2 000

10 000

6 000

8 000

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Health systems in transition Portugal142

Fig. 9.6PYLL – health care promotion, 1990–2003

Source : OECD, 2009.

Fig. 9.7PYLL – selected causes, forecast, 1990–2030

Source : OECD, 2009.

0

1990 1995

Lung cancer Skin cancer Ischaemic heart diseaseCirrhosis Land transport accidents

2000 2005

200

1 000

800

600

400

0

1990 2000

Lung cancer Skin cancer Ischaemic heart diseaseCirrhosis Forecast

20202010 2030

100

300

200

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Health systems in transition Portugal 143

/XQJ�DQG�VNLQ�FDQFHU�UDLVH�FRQFHUQV�DV�FDXVHV�RI�GHDWK��JLYHQ�WKHLU�LQFUHDVLQJ�WUHQG��,I�WKH�1DWLRQDO�+HDOWK�3ODQ�����±�����LV�DEOH�WR�DFKLHYH����KHDOWK�JDLQV�LQ�WKHVH�WZR�FDXVHV��WKH�YDOXHV�FRXOG�EH�DV�ORZ�DV������OXQJ��LQVWHDG�RI������DQG�����VNLQ��LQVWHDG�RI�����3<//�SHU���������LQKDELWDQWV��)LJ�������

Fig. 9.8PYLL – scenarios, 1990–2030

Source : OECD, 2009.

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0

50

1990 2000

Lung cancer Skin cancer ForecastPessimistic scenario Optimistic scenario

2010 2020 2030

100

200

150

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Health systems in transition Portugal144

Fig. 9.9PYLL – land transport accidents, 1990–2030

Source : OECD, 2009.

9.1.3 Standardized death rates

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)LJ�������VKRZV�WKH�HYROXWLRQ�DQG�SRVVLEOH�VFHQDULRV�RQ�WKH�6'5�RI�OXQJ�DQG�VNLQ�QHRSODVPV��,I�WKH�1DWLRQDO�+HDOWK�3ODQ�����±�����LV�DEOH�WR�KDYH�D�QHJDWLYH����LPSDFW�LQ�WKH�OXQJ�DQG�VNLQ�QHRSODVPV�6'5��WKHQ�E\�������ZH�FDQ�SUHGLFW�WKDW�WKH�VNLQ�QHRSODVP�6'5�FRXOG�EH�DV�ORZ�DV�����SHU���������SRSXODWLRQ��DQG�OXQJ�QHRSODVP�6'5�FRXOG�GHFUHDVH�WR�������YHUVXV�D�SUHGLFWHG�YDOXH�RI�������LQ�������)LQODQG�KDG�D�VLPLODU�6'5��������

200

1990 2000

Land transport accidents ForecastPessimistic scenario Optimistic scenario

20202010 2030

400

600

1 000

800

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Health systems in transition Portugal 145

Fig. 9.10SDR – per 100 000 population, 1990–2003

Source : OECD, 2009.

Fig. 9.11SDR – selected causes, forecast, 1990–2030

Source : OECD, 2009.

400

1990 1995 2000 2005

600

800

1 200

1 000

Population Men Women Forecast

0

1990 2000

Cerebrovascular disease Ischaemic heart diseaseNeoplasms Forecast

20202010 2030

100

50

200

150

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Health systems in transition Portugal146

Fig. 9.12SDR – scenarios, 1990–2030

Source : OECD, 2009.

9.2 References

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0

1990 2000 2010 2020 2030

10

30

20

Lung cancer Skin cancer ForecastPessimistic scenario Optimistic scenario

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Health systems in transition Portugal 147

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9.3 Further reading

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9.4 Useful web sites

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All HiTs are available in English.When noted, they are also available in other languages:a Albanianb Bulgarianc Frenchd Georgiane Germanf Romaniang Russianh Spanishi Turkishj Estoniank Polishl Tajik

HiT country profiles published to date:

Page 179: Portugal HiT (2011) _ Health System Review

The

Euro

pean

Obs

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tory

on

Heal

th S

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nd P

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s a p

artn

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ip b

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the

WHO

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the

Gove

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of B

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inla

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rela

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ther

land

s, No

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, Slo

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pain

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and

the

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k, th

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sura

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& T

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HiTs

are

in-d

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pro

files

of h

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prod

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figur

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alys

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form

initi

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pro

gres

s.

ISSN

18

17-6

127