By: Jessica Wiken, Alexandre Lourenço, José Maria Albuquerque, Madeline Pesec, and Jocelyn Fifield

Introduction and context: PHC reform in Portugal, from the 1970s to present

In the 1970s, Portugal emerged as one of the first European countries to adopt a tax-financed national health system with an integrated approach to primary health care (PHC). 1 Since then, Portugal has worked to ensure equal access to health care as a right for all its citizens through a series of laws and national reforms and the creation of a nationwide health centre network. 1 2 3 4 5 The creation of the National Health Service (Serviço Nacional de Saúde, SNS) in 1979 established the State as the provider of this right to universal, comprehensive, and free health care. In practice, Portugal faced many difficulties fulfilling this role due to financial, organizational, and access-related limitations within the greater context of political, economic, and social changes as it decolonized and transitioned to democracy. 5

Portugal’s health care system has undergone frequent reforms over the last 40 years as changing political forces impact the health agenda. 2 5 6 Many of these reforms have focused on increasing health sector efficiency through autonomous and flexible management strategies. 2 5 Facing ongoing issues with accountability, efficiency, and cost-containment 7, the strategic goals of the New National Health Care System period of 2002 - 2006 and the National Health Plan period of 2004 - 2010 were designed to achieve health gains through health promotion and disease prevention with an emphasis on integrated PHC. 1 5 6 In 2005, Portugal’s PHC system underwent major reform as a part of the National Health Service Mission for PHC (Cuidados de Saúde Primários). 1 2 Building on previous reforms, the National Health Service Mission aimed to improve accessibility, organization, timeliness, and ease of use of quality services through decentralized governance and community-based PHC. 1 2 Considered one of the most successful public reforms in Portugal, the National Health Service Mission broke from the traditional hierarchical model and restructured the health system using both a bottom-up and top-down approach to respond to population health needs at local, regional, and national levels. 2 3 8

While Portugal continues to aim for high-quality, universal PHC, the capacity of the SNS to achieve the aims of these reforms has depended on the fluctuating economic and political pressures on the State. 5 In reaction to the 2008 global economic crisis, Portugal agreed with the EU to an Economic Adjustment Program between 2011 and 2014 aimed at improving cost-containment, transparency, and regulation in the health sector, as a condition of a EUR 78 billion international loan agreement. 9 10 Portugal’s latest reforms have responded to these pressures to improve financial sustainability and efficiency. 9 In commitment to the series of reforms over the last few decades, Portugal has also worked to improve the efficiency and quality of its health system through innovative care-coordination strategies and comprehensive community-based health promotion programs. 2 9 As a reflection of these efforts, Portugal has enjoyed substantial improvements in the health status of its population over the last 25 years despite having some of the lowest economic and education indicators in Western Europe. 3 11 This case study focuses on reforms in Portugal in this context, with a specific focus on both horizontal and vertical care integration models for improved coordination of care.

Strengthening coordination across the health system: decentralization and integration

The Ministry of Health oversees the Portuguese health system and is responsible for regulating, monitoring, and financing the national health system through the National Health Plan. 9 10 Central funding is distributed to Regional Health Authorities, who are responsible for the coordination of hospitals and management of traditional primary health care centres in regional districts, as well as the implementation of national health policy objectives. 2 9 16 A 1993 SNS statute redefined the organization of these districts into five health regions. 5 Local primary health care provision is split between two models, the traditional primary health care centres and primary care services grouped in Family Health Units (Unidades de Saúde Familiar).

Organizational changes implemented as a part of the 2005 reform led to the creation of Health Center Groups (Agrupamentos de Centros de Saúde) in 2008. 2 5 9 13 The Health Center Groups are decentralized public health services under the Regional Health Authorities that have administrative autonomy and are responsible for populations between 50,000 and 200,000. 1 2 3 6 12 Prior to the creation of these groups, policy initiatives borne of the 2005 reform reorganized the incentive structures and funding of PHC to promote the evolution of traditional primary health care centres into Family Health Units. 1 3 4 12 Traditional primary health care centres were incentivized to organize as Family Health Units through an internal contractualization process in which primary health care teams defined collective performance-related objectives around access, efficiency, and quality. 8 Facing resource management issues, the Health Center Groups were created to build an organizational framework and support structure for community-based PHC. 1 3 4 12 Five different functional units, including the Family Health Units, operate under the management of Health Center Groups but have technical, functional, and organizational autonomy. 2 3

Portugal’s existing health system structure reflects the efforts of historical reforms to improve coordination across levels of care to provide equitable access to a more comprehensive set of services across the continuum of care, with primary care at the centre of the system. Through care integration processes, Portugal has worked to improve the efficiency and accessibility of quality primary health care for all.

Horizontally integrated care initiatives - multidisciplinary teams and intersectoral collaboration

Horizontal integration refers to the coordination and consolidation of multiple types of health care services within PHC facilities and in community-based care. In Portugal, the Family Health Units have contributed significantly to the provision of this people-centred, integrated model of PHC. Considered a cornerstone of the 2005 reform, Family Health Units are self-organized, autonomous multidisciplinary groups comprising three to eight family doctors with an equal number of family nurses and administrative professionals. These Family Health Units operate in health centers run by the State have a targeted focus on access, care coordination, and high-quality continuous care. 2 3 4 Their core mission is to engage in local priority setting and deliver customized and equitable PHC to a population of between 4,000 and 18,000 individuals in their geographic area. 2 3 6 13 Task sharing among members of the team helps to promote coordination and multidisciplinary collaboration. 2 As a part of the bottom-up approach of the 2005 reform, functional health units like the Family Health Units hold technical responsibilities and authority independent of the management of Health Center Groups but work in accordance with principles and directives issued in regional plans and by the Ministry of Health. 2 6 8 13 In the first three years of the reform, Portugal saw an increase in the percent of patients who visited their usual primary care provider at least once a year from 59.8% in 2005 3 to 67.6% in 2017; and 89.4% with a medical appointment in the last three years. 14

Facing issues with worker retention and quality performance in the public sector, especially in rural areas, a new payment scheme was developed to incentivize performance and integrated care delivery. 13 15 To encourage greater autonomy, certain Family Health Unit teams determine the performance-related indicators and goals that they are measured against. 2 15 Achievement of these goals qualifies these teams for both team-based and individual performance-based incentives that are determined through consideration of the patient list, opening hours, and home visits. To further promote the delivery of comprehensive, coordinated care, additional incentives are in place to monitor higher-risk subpopulations, such as pregnant women and diabetic patients, coordinate across different levels of care, and promote public health activities such as tobacco cessation programs. 2 15 Notably, Family Health Unit teams in the learning phase receive exclusively team-based financial incentives. 2 18 The Family Health Unit model has shown better access to care and improved clinical performance -- including better management of hypertensive and diabetic patients -- relative to traditional primary health care centres that did not undergo contractualization to Family Health Unit models. 15

In addition to the Family Health Units, Portugal has used intersectoral collaboration as a strategy to better meet patients’ comprehensive needs through initiatives like the National Network for Long-term Care (2006). This program provides long-term, home-based care and social support through a horizontal network of long-term care providers that links PHC groups, social security services, and private institutions providing social services. 9 19 Another recent measure has aimed to better manage diabetes and reduce wait times across all levels of care delivery through the creation of Functional Coordinating Units for Diabetes (2013). 9

Vertically integrated care initiatives - multidisciplinary collaboration across the care continuum

Vertical integration involves redefining the role and improving the interactions among primary, secondary, and tertiary facilities to promote better care coordination across levels of care. Portugal started vertical integration in 1999 with the creation of Local Health Units (Unidade Local de Saúde) which integrate hospital and primary health care units in the same geographical area to promote multidisciplinary collaboration and coordination across different levels of care. 4 10 The Local Health Unit model was created due to systemic problems with a lack of coordination and information sharing across different levels of care and the large number of patients bypassing the referral system for ambulatory care needs. 9 Local Health Units have become a resource for providing effective and coordinated care to patients with multiple needs. In 2014, there were eight Local Health Units in Portugal. Since 2009, the Local Health Units have been financed through a mixed model including an adjusted capitation, pay for performance, and service level agreements, which take into account patient flow to and from the catchment area. 17 Although improvements were inconsistent across Local Health Units, there was an association between integrated care and reduced hospital readmissions in vertically-integrated units, especially for diabetes patients. 12 16

The challenges of sustained motivation for integrated care delivery

Despite these strides, many of these integrated care initiatives have been limited in scope or stalled in large part due to the impact of financial constraints on Portugal’s management and economic models. 4 13 15 While Portugal’s agreement to rationalize public-sector health spending helped to promote the use of primary care, salary freezes and the removal of various compensation schemes have created issues with worker retention and motivation among primary care providers. As a result, Portugal continues to experience issues with the migration of the qualified healthcare workforce out of rural areas to metropolitan areas and to speciality and hospital-based services in the private sector. 6 These shortcomings challenge the capacity of integrated care teams that are motivated by a pay-for-performance model to effectively serve as the first point of contact, especially in rural areas. 12 Creating and sustaining effective and efficient horizontal and vertical integration initiatives is resource and time intensive. Achieving increased access to effective PHC will require a long-term, system-wide commitment to coordination across and within levels of care, and an investment in physical, technical, and human resources, including strong information technology networks and workforce training programs.

Moving forward: investing in integration across the continuum of care

Portugal has made great strides to promote multidisciplinary team-based care and implement innovative integrated-care models. Given the demonstrated potential of Portugal’s integrated care models to improve both access and health outcomes, it is especially important for future policy initiatives and investment funds to address the financial constraints challenging the operations of integrated care models. In light of the growing burden of chronic diseases, Portugal’s integrated care programs are critical strategies for efficiently managing complex illnesses. 8 10 12 16 

As seen through the National Network for Long-term Care, multisectoral engagement can be a valuable strategy to promote collaboration and increase efficiency through the provision of complementary services. However, robust quality initiatives -- including standards of care, clinical guidelines, and accreditation standards -- and strong information systems must continue to be a priority for all actors involved in the delivery of care, to ensure the delivery of safe, timely, and high-quality services across the continuum of care. 17 In Portugal, important opportunities lie in increasing community engagement efforts, multisectoral collaboration, and innovations in health information technology to deliver more comprehensive responses to address complex population health needs.


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