Jorge Simões

President of the Board

Porto, 8 May 2014

The Portuguese health system and its regulation

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I. The Portuguese health system

II. Challenges for the health system

III. The Health Regulation Authority (ERS)

Outline

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I. The Portuguese health system

General characterization

The Portuguese health system is characterized by three layers:

The National Health Service

Public insurance schemes for certain professions (health subsystems)

Voluntary private health insurance

The Portuguese health system is a mixed system, with a combination of public and private funding, and also public and private provision

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Public and private mix in funding

Source: INE (2013), Health Care Satellite Account (2012)

Current expenditure in healthcare, Portugal 2012

I. The Portuguese health system

  EUR million Percentage

Public funding 9,790 62.6%

- National Health Service 8,439 54.0%

- Public professional subsystems 585 3.7%

- Other public funding 765 4.9%

Private funding 5,839 37.4%

- Private subsystems 288 1.8%

- Voluntary health insurance 503 3.2%

- Out-of-pocket payments 4,947 31.7%

- Social funding 100 0.6%

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Public and private mix in provision

Proportion of total consultations in private providers, Portugal, 2005

Source: Simões, Barros and Pereira (2008)

Specialty % private consultations

Dental Care 92.1%

Gynecology 67.6%

Ophthalmology 66.9%

Cardiology 54.2%

Orthopedics 45.5%

Pediatrics 31.1%

Primary care 17.1%

I. The Portuguese health system

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Access and equity

Primary health care:

only 0.03% of the population lives more than 30 minutes away from a NHS primary care facility (ERS, 2009)

85.2% are assigned to a family doctor (ACSS, 2010)

Hospital care:

88% of the population lives less than 30 minutes away and only 1% of the population lives more than 60 minutes away from a hospital

asymmetries in the concentration of medical specialists, which is higher in the region of LVT and lower in Alentejo and Algarve

I. The Portuguese health system

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Access and equity

Vaccination:

immunization rates above 90% and inclusion of new vaccines in the National Plan of Vaccination

Dental Care Programme

Set up in 2005 within the NHS, covers basic dental care for children, aged people with economic difficulties, pregnant women and HIV positive individuals

I. The Portuguese health system

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Health gains

From 2000 to 2012:

life expectancy at birth increased from 76.4 to 79.9 years;

under 1 year mortality rate decreased from 5.5 to 3.4‰.Source: INE (2013)

I. The Portuguese health system

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Expenditure on health

Source: OECD, Health Data 2012

Exp

end

itu

re o

n h

ealt

h a

s %

of

GD

PI. The Portuguese health system

0,0

2,0

4,0

6,0

8,0

10,0

12,0

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

Portugal Média OCDE

Portugal – 10,2%OCDE average – 9,3%

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I. The Portuguese health system

II. Challenges for the health system

III. The Health Regulation Authority (ERS)

Outline

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II. Challenges for the health system

1) Demographic context

2) Economic context

3) Financial sustainability

4) Europe

5) Regulation

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1) Demographic context

15% of residents in Portugal are aged under 15 years and 19% are over 65 years (INE, 2012)

In the last decade (2001-2011): old-age dependency ratio increased (24.5 to 29.0) natural growth rate became negative (0.07 to -0.06) total fertility rate decreased (from 1.46 to 1.37) (INE, 2012) life expectancy at birth increased from 76.4 to 79.7 years

Forecast for 2020: a 2% decrease in population, a 13.8% decrease in youth (0-14 years) and a 20.6% increase in elderly (≥ 65 years).

II. Challenges for the health system

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2) Economic context

II. Challenges for the health system

100.000

110.000

120.000

130.000

140.000

150.000

160.000

170.000 1

99

5

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

-4%

-3%

-2%

-1%

0%

1%

2%

3%

4%

5%

6%PIB a preços de 2006 Taxa de crescimento

GD

P i

n m

illi

on

of

EU

RR

eal gro

wth

rate of G

DP

Source: INE, 2013

Gross Domestic Product, Portugal

GDP (prices of 2006) Growth rate

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II. Challenges for the health system

3) Financial sustainability

“Memorandum of Understanding” signed with IMF and EU, for the health sector, sets:

revision of existing user fee exemption categories (more 150 M€ in 2012 e 50 M€ in 2013)

reduction in public expenditure on drugs (1.25% of GDP in 2012, 1% of GDP in 2013)

hospitals costs: reduction in operational expenditures of 200 million euros (in 2012)

reduction in budgetary costs of public subsystems (ADSE, ADM and SAD) by 30% in 2012 and 20% in 2013, achieved by reducing the benefits to users

reduction in expenditure of the NHS with the acquisition of private diagnostic and therapeutical services in 10% in 2012.

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4) Europe

EU Directive on cross-border healthcare:

facilitate access to cross-border healthcare in the EU

II. Challenges for the health system

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II. Challenges for the health system

5) Regulation

Financial pressure in health care generates risks to patients:Management of health care units increasingly oriented by

financial targetsPerformance targets may collide with patients rights and

interestsContainment of global investment on health

Health regulator is essential to balance sustainability measures and ensuring patients rights and interests

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I. The Portuguese health system

II. Challenges for the health system

III. The Health Regulation Authority (ERS)

Outline

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Who we are

Mission of the Health Regulation Authority (ERS)

Regulating the activity of health care providers in Portugal (drugs and medical devices are excluded)

Nature

ERS is an independent public body

Juridical regime Decree-Law no. 309/2003 – creation of ERS

Decree-Law no. 127/2009 – restructuring

Decree-Law no. 66/2014 – restructuring under the new framework law for independent regulation in Portugal

III. The Health Regulation Authority

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Who we regulate

All health care providers, public, private for-profit and private not-for-profit ownership

All types of providers

Hospitals

Individual physician's offices

Outpatient care clinics

Diagnostic tests providers

Dentist offices and clinics

(…)

III. The Health Regulation Authority

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What we do

The ERS aims at delivering independent assurance about:

the compliance with the legal requirements for health care services and establishments,

the protection of health care service users rights, including access and freedom of choice,

the legality and transparency in the economic relations between providers, funders and users,

fair competition in health care markets.

III. The Health Regulation Authority

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How we do it

ERS carries out several regulation and supervision activities:

registering and licensing health care providers,

handling complaints from service users, providers and institutions,

carrying out inspections and audits to heath care provider facilities,

carrying out investigations of situations with significant adverse impact on the rights of patients or on the quality and safety of care,

conducting administrative offence procedures involving health care providers and applying the resulting sanctions,

producing studies, advice papers and recommendations,

assessing the quality of health care (SINAS)

III. The Health Regulation Authority

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Providers registered with the ERS

III. The Health Regulation Authority

6.1907.518 8.147 8.481

9.19810.151 10.808 11.385

8.778

10.65911.752 12.496

13.68215.085

16.25217.160

2006 2007 2008 2009 2010 2011 2012 2013

Ent. Registadas Estab. Registados

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Complaints handled in 2013

III. The Health Regulation Authority

Subject of complaint number %

Administrative service quality 2.019 24,7%

Health care quality 1.765 21,6%

Waiting times 1.762 21,6%

Financial issues 794 9,7%

Invalid complaint 596 7,3%

Access 396 4,9%

Human assiance 340 4,2%

Facilities 228 2,8%

Legal issues 143 1,8%

Other 102 1,3%

Discrimination 15 0,2%

Total 8.160 100%

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Investigations initiated in 2013

III. The Health Regulation Authority

Subject number %

Quality 26 27%

Legal issues 26 27%

Access 20 21%

Transparency 12 13%

Contracting with NHS 4 4%

Service billing 4 4%

Discrimination 1 1%

Supplier induced demand 1 1%

Other 1 1%

Total 95 100%

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Inspections carried in 2013

Inspections focus Number %

Legal requirements of health care establishments 984 79%

Thematic reviews 169 14%

Audits related to SINAS 61 5%

Quality of health care 33 3%

Total 1.247 100%

III. The Health Regulation Authority

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Administrative offence procedures initiated in 2013

III. The Health Regulation Authority

Offence Number %

Non compliance with licensing rules 223 40%

Not registered with the ERS 203 37%

Not owning a Complaints Book 87 16%

Irregular handling of Complaints Book 19 3%

Refusal to collaborate with the ERS 10 2%

False declarations or information 7 1%

Other legal issues 7 1%

Total 556 100%

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Studies, advice papers and recommendations (2012/2013)

Topics of analysis:

Quality of health care (4)

Inequalities in access to health care (5)

Competition in health care markets (4)

Regulation of economic relations (2)

Patient rights safeguarding (4)

Organization and performance of the NHS (4)

III. The Health Regulation Authority

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Our people

The Board

ERS is managed by a Board of three members (one of which is the president)

Appointed by the Government for a period of 5 years

Staff

51 permanent employees

external experts (doctors, nurses, dentists)

III. The Health Regulation Authority

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Independence

Independence of Board members

Cannot be dismissed (except in cases of serious failure)

Cannot be involved in regulated activities

100% funded from registration fee income

Public accountability

Reporting activities to the Parliament and the Government

Advisory board

Activity is overseen by Court

III. The Health Regulation Authority

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With whom we network

Professional associations

Patient associations

Health care providers

Government health related institutions

Regulators of other sectors

Academic institutions and experts

European health care regulators (EPSO)

III. The Health Regulation Authority

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Impact of ERS activity

Better knowledge of the health system – registration, sectoral studies;

Greater empowerment of citizens – complaints and information;

Better assurance of user rights – control of access rights;

Better knowledge of health care markets – competition studies;

More safety – licensing, supervision and sanctioning;

More quality – quality assessments and studies.

III. The Health Regulation Authority

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