Performance evaluation and management
contracts in primary healthcare in Portugal: What
lessons have been learned ?
Márcia Silveira Ney1
Luis Velez Lapão2
Celia Regina Pierantoni3
Context
The primary healthcare reform enabled the emergence
of new organizational arrangements with significant
innovations in management process and practices in
health services to achieve the principles of universality
and ensuing access, effectiveness, sustainability,
governance and higher quality of services.
The Primary HealthCare Reform started in 2005 in
Portugal. The reform held a strong strategic
perspective, at a time of political and institutional
environment, with an extensive restructuring of the
health centers, the creation of Family Health Units, and
groups of health centers, enabling the introduction of a
new management, based on performance evaluation on
negotiated contracts.
Figure 1. The primary health care reform should be
thought as the introduction of na innovative product
Initiation
Planning
Execution
Maturity
PACES
Acessibility
APMCG
Complexity
Evidence
Contractualization
USF
SIADAP
1971 1978
CS
Alma
1ªG -Ata
1989
1982
CS
2ªG
SNH
1996
CS
3ªG
Alfa
RRE
SLS
2004
2005
MSCP
2006
USF
2008
ACES
ACES
2.0
time
New Public Management
Methods
Object: Analyze the management processes implemented in the Primary Health Care (PHC) in Portugal since 2005,
regarding the introduction of “Performance Evaluation” methods and Contracting between Primary-care Units and the
Ministry of Health.
Methods: An exploratory study, descriptive, using a qualitative approach. The data collection consisted of a literature
review and interviews with managers leading of Health Centers in Lisbon Region.
Results
The implementation of a new structure for the coordination of family health units in Health Centers allied with new
public management to strengthen the management capacity of leaders and the regulation of a performance system
evaluation for professionals in public administration has contributed to improve the Primary Healthcare management in
Portugal, mostly by deploying a system with managers closer to the professionals and their problems.
It can be seen as a contribution of a positive impact on the contracting process: a significant reduction in public
spending, the adoption of management by objectives, the implementation of clinical governance, team work, greater
accountability to the people, larger autonomy of the services and appreciation of professional merit.
The evaluation process involves technical performance evaluation of professionals, related with their skills and abilities.
However, even with institutionalized rules there was still resistance from professional groups such as physicians and
nurses to adhere. In fact, the organization is not providing enough support to enable faster diffusion of the new
system.
Discussion
The integration of evaluation processes within the
primary-care management processes, for both
professional performance and services contracting,
allowed a systematic and integral evaluation towards
the building of a new culture of apprenticeship,
innovation, and continuous quality improvement of
services.
This experience raises discussions on policies that
have been implemented under the Primary Health
Care in several countries, enabling discussions for
future research such as performance appraisal process
more technical, with measures in the focus of
management and prevention of chronic diseases.
Figure 2. Management by objectives in primary health
care reform
Leadership
Negotiation and
contractualization
Management
by objectives
Culture and
learning
Pay for
performance
incentives
Follow
management support
Based in Peter Drucker 1954 (The Practice of Management)
1 - Medical, Doctoral Student of Public Health at Institute of Social Medicine/UERJ, Brazil and Institute of Hygiene and Tropical Medicine (IHMT),
Universidade Nova de Lisboa, Portugal.
2 - Health Management Professor at the Health Systems Units, at the Institute of Hygiene and Tropical Medicine (IHMT), Universidade Nova de
Lisboa, Portugal
3 - Medical. PhD in Public Health. Associate Professor of IMS / UERJ. General Coordinator of Network Observatory of Human Resources in HealthWorkstation at IMS / UERJ. Director of the Collaborating Centre PAHO / WHO for Planning and Information Workforce for Health.