Background
Crises and health system performance: where do we stand in the debate?
The situation in Portugal
Policy outcome | ||||||
---|---|---|---|---|---|---|
Accomplished | Partially accomplished | Not accomplished | Withdrawn/omitted | |||
Cost sharing | Review and increase patient fees | x | ||||
Reduction of exemption categories | x | |||||
Increase inflation-indexed fees | x | |||||
Cut tax allowances for healthcare, including private insurance | x | |||||
Reduce the cost of health benefits schemes for public servants | x | |||||
Reduce costs for patient transportation | x | |||||
Regulation of the drug market | Control retail price | x | ||||
Move the responsibility of pricing to the Ministry of Health | x | |||||
Revise the international reference-pricing system | x | |||||
Monitor expenditure monthly and limit public spending | x | |||||
Remove barriers to generic medicines | x | |||||
Change the calculation of pharmacies’ profit margin | x | |||||
Gradually increase the share of generic medicines | x | |||||
Implement existing legislation on the regulation of pharmacies | x | |||||
Speed up the reimbursement of generics | x | |||||
Introduce a contribution paid by pharmacies | x | |||||
Control of doctors’ prescription | Make electronic prescription of medicines and diagnostic tests covered by public reimbursement fully compulsory for physicians (public and private sectors) | x | ||||
Encourage physicians to prescribe generic medicines and less costly branded products (public and private sectors) | x | |||||
Introduce international prescription guidelines for drugs, exams and treatment | x | |||||
Improve monitoring of prescription of medicines and diagnostic services and impose systematic assessments by each doctor of quantity and cost. Introduce sanctions and penalties | x | |||||
Control of operating costs and performance in the NHS | Legislative and administrative framework for a centralized procurement system for the purchase of medical goods | x | ||||
Change in the existing accounting framework in hospitals SOEs to that of private companies and other SOEs | x | |||||
Concentration and rationalization of non-hospital care provision | x | |||||
Concentration and rationalization of the hospital network | x | |||||
Continued publication of clinical guidelines and introduction of an auditing system | x | |||||
Benchmarking of hospital performance | x | |||||
Interoperability of IT systems in hospitals | x | |||||
Finalization and regular updates of uniform coding system for medical supplies | x | |||||
Implement the centralized purchasing of medical goods using the uniform coding system | x | |||||
Clearing of existing arrears in the hospital sector and prevention of accumulation of new arrears | x | |||||
Completion of patient electronic medical records | x | |||||
Public-private relationship | Increase in competition between private providers and reduction in NHS payment of exams and treatments | x | ||||
Centralized monitoring of public-private partnership contracts | x | |||||
Regular revision of fees paid by the NHS for exams and treatment by private providers | x | |||||
Assessment of compliance with European competition rules for the provision of services in the private healthcare sector | x | |||||
Access to healthcare | Reinforce primary health care | Increase the number of patients per primary care unit/family doctor | x | |||
Increase the number of primary care units using salary and performance-related payments | x | |||||
Separate HR from hospitals and reconsider the role of nurses and other professionals | x | |||||
Review geographical distribution of GPs | x | |||||
Move hospital outpatient services to primary care units | x | |||||
Workforce | Update working time, increase mobility, adopt flexible time arrangements and review payment mechanisms | x | ||||
Conduct an annual inventory of doctors | x | |||||
Make human resource allocation plans | x | |||||
Increase mobility of healthcare staff within and between regions | x | |||||
Ensure transparent selection of the chairs and members of hospital boards | x |
Objectives of the study
Methods
Study design and participants
Measures
Dependent variables
-
-Administrative interference in decision making, i.e., less autonomy in physicians’ decision-making in favor of organizational control: more rejections of innovative treatments (DV1), pressure to choose cheaper treatments exerted by the administration (DV4), and pressure not to prescribe certain drugs exerted by the administration (DV5)
-
-Insufficient resources, i.e., possible limitation of material resources for the provision of care: regular shortages of supplies (gloves, masks, needles, etc.) (DV2) and regular shortages of drugs (DV3)
-
-Deterioration in medical residency, i.e., organizational changes that directly affected physicians’ advanced training: less favorable conditions for medical residencies (DV6) (e.g., overworked residents and less time for tutors’ work)
Independent variables
Moderator variables
Data analysis
Results
Descriptive statistics
Analyses variables and categories |
N
| % | |||
---|---|---|---|---|---|
Independent variable | Sector of activity | Exclusive in public | 1209 | 58.6 | |
Exclusive in private | 854 | 41.4 | |||
Total | 2063 | 100.0 | |||
Exclusive in public | Primary healthcare | 509 | 42.1 | ||
Public hospitals | 634 | 52.4 | |||
Non answer | 66 | 5.5 | |||
Total | 1209 | 100.0 | |||
Exclusive in private | Small-size offices | 274 | 32.1 | ||
Clinics | 230 | 26.9 | |||
Hospital | 79 | 9.3 | |||
Non answer | 271 | 31.7 | |||
Total | 854 | 100.0 | |||
Moderator variables | Years of practice | Up to 12 years | 644 | 31.2 | |
13–25 years | 473 | 22.9 | |||
26–39 years | 520 | 25.2 | |||
Over 40 years | 426 | 20.0 | |||
Total | 2063 | 100.0 | |||
Medical specialty | Anesthesiology | 59 | 2.9 | ||
Cardiology | 28 | 1.4 | |||
Dermatology | 17 | .8 | |||
Gastroenterology | 23 | 1.1 | |||
General practice/family medicine | 498 | 24.1 | |||
General surgery | 110 | 5.3 | |||
Internal medicine | 132 | 6.4 | |||
Neurology | 16 | .8 | |||
Obstetrics and gynecology | 78 | 3.8 | |||
Oncology | 38 | 1.8 | |||
Ophthalmology | 41 | 2.0 | |||
Orthopedics | 49 | 2.4 | |||
Other surgical specialties | 54 | 2.6 | |||
Otorhinolaryngology | 29 | 1.4 | |||
Pediatrics | 109 | 5.3 | |||
Physical medicine and rehabilitation | 26 | 1.3 | |||
Psychiatry | 64 | 3.1 | |||
Public Health | 28 | 1.4 | |||
Pulmonology | 31 | 1.5 | |||
Radiology | 36 | 1.7 | |||
Stomatology | 30 | 1.5 | |||
Non answer | 567 | 27.5 | |||
Total | 2063 | 100.0 | |||
Dependent variables—quality of care | DV1 | No | 1465 | 82.7 | |
Yes | 307 | 17.3 | |||
Total | 1772 | 100.0 | |||
DV2 | No | 639 | 35.1 | ||
Yes | 1184 | 64.9 | |||
Total | 1823 | 100.0 | |||
DV3 | No | 1149 | 69.4 | ||
Yes | 506 | 30.6 | |||
Total | 1655 | 100.0 | |||
DV4 | No | 1384 | 76.2 | ||
Yes | 432 | 23.8 | |||
Total | 1816 | 100.0 | |||
DV5 | No | 1819 | 84.4 | ||
Yes | 336 | 15.6 | |||
Total | 2155 | 100.0 | |||
DV6 | No | 747 | 51.1 | ||
Yes | 716 | 48.9 | |||
Total | 1463 | 100.0 |
Group comparisons
Sector of activity | DV1 | DV2 | DV3 | DV4 | DV5 | DV6 | |
---|---|---|---|---|---|---|---|
Meana
| Mean | Mean | Mean | Mean | Mean | ||
1st step | |||||||
Public | 0.153 | 0.731 | 0.300 | 0.262 | 0.200 | 0.435 | |
Private | 0.134 | 0.228 | 0.110 | 0.158 | 0.058 | 0.571 | |
Model test |
t (1026) = 0.683 |
t (1054) = 14.379*** |
t (938) = 4.809*** |
t (1049) = 3.001** |
t (1276) = 6.044*** |
t (684) = − 2.436* | |
2nd step | |||||||
Public | Primary healthcare | 0.065 | 0.847 | 0.091 | 0.351 | 0.267 | 0.385 |
Public hospitals | 0.234 | 0.637 | 0.437 | 0.201 | 0.143 | 0.471 | |
Model test |
t (786) = − 6.663*** |
t (815) = 6.893*** |
t (751) = − 10.914*** |
t (820) = 4.869*** |
t (910) = 4.741*** |
t (554) = − 1.996* | |
Private | Small-size offices | 0.286 | 0.125 | 0.100 | 0.161 | 0.056 | 0.636 |
Clinics | 0.074 | 0.333 | 0.129 | 0.239 | 0.061 | 0.308 | |
Hospital | 0.167 | 0.188 | 0.133 | 0.194 | 0.100 | 0.750 | |
Model test |
F (2, 116) = 3.682* |
F (2, 115) = 2.768 |
F (2, 78) = 0.0660 |
F (2, 105) = 1.609 |
F (2, 201) = 0.514 |
F (2, 48) = 3.299* |
Moderator analysis
DV1 | DV2 | DV3 | DV4 | DV5 | DV6 | |
---|---|---|---|---|---|---|
Exclusive in publica
| 1.556 | 1.160*
| − 0.104 | − 0.115 | − 0.814 | 0.571 |
(0.857) | (0.580) | (0.714) | (0.640) | (0.710) | (0.692) | |
Years of practice (exclusive in private) | 0.002 | − 0.003**
| − 0.005**
| − 0.002 | − 0.006**
| 0.001 |
(0.002) | (0.001) | (0.002) | (0.002) | (0.002) | (0.002) | |
Exclusive in public * Years of practiceb
| − 0.005*
| 0.002 | 0.002 | 0.002 | 0.005**
| − 0.004*
|
(0.002) | 0.001 | (0.002) | (0.002) | (0.002) | (0.002) | |
Constant | − 2.742**
| 0.212 | − 0.229 | − 0.775 | − 0.522 | 0.172 |
(0.843) | (0.563) | (0.703) | (0.626) | (0.694) | (0.645) | |
Model LL = | 18.316***
| 186.426***
| 57.636***
| 13.628**
| 52.207***
| 24.265***
|
Post hoc tests | ||||||
Years of practice (exclusive in public) | − 0.003***
| − 0.002**
| − 0.003***
| − 0.002**
| − 0.002 | 0.000 |
(0.001) | (0.001) | (0.002) | (0.001) | (0.001) | (0.002) |
DV1 | DV2 | DV3 | DV4 | DV5 | DV6 | |
---|---|---|---|---|---|---|
Sector |
F (1, 595) = 0.842 |
F (1, 609) = 68.809*** |
F (1, 520) = 23.010*** |
F (1, 606) = 0.006 |
F (1, 764) = 0.571 |
F (1, 382) = 2.038 |
Medical specialty |
F (11, 595) = 2.701** |
F (11, 609) = 3.447*** |
F (11, 520) = 0.898 |
F (11, 606) = 1.130 |
F (11, 764) = 1.143 |
F (11, 382) = 0.927 |
Interaction between sector and medical specialty |
F (11, 595) = 1.988* |
F (11, 609) = 1.370 |
F (11, 520) = 4.206*** |
F (11, 606) = 0.993 |
F (11, 764) = 0.822 |
F (11, 382) = 1.353 |