PRIMARY HEALTH CARE IN PORTUGAL
THE NEED FOR AN EFFECTIVE
DECENTRALIZATION
PATRÍCIA BARBOSA
NOVA UNIVERSITY OF LISBON
PORTUGAL
GOTHENBURG, 3rd AND 4th SEPT 2012
In the early 70’s Portugal was one of the
first European countries adopting the
concept of “Health Centres”
HEALTH CENTRE
Community health centre network
covering the entire country
About 360 health centres (organized at
council level) and a large number of
“extensions” – small units organized at
local level
ORGANIZATIONAL STRUCTURE OF PHC BETWEEN 70’S AND 2005
Ministry of Health
Regional Health
Administrations (5)
Health
extension
Sub-regional
health
administrations
(18)
Health
extension
Health
Centre
Health
extension
Health
extension
Health
Centre
Health
extension
Health
extension
Health
extension
Health
Centre
Health
Centre
Health
extension
Health
extension
Health
extension
Health
Centre
Health
Centre
Health
extension
Health
extension
Health
extension
Health
Centre
Health
Centre
Health
extension
Health
extension
“Command- and –
control” structure of
“regional” health
administrations
CONSEQUENCES TO THE PHC
•Total dependency of regional health administrations
• No autonomy
• Lack of administration and management
• Centered in the structure and the professions (doctors and nurses)
• Without technique hierarchy
• Incipient information system
• Vertical and rigid hierarchy
• Health care “medicalization”
• Without contracting or incentives
• Inability to incorporate new health professions and their technological
components
Despite the quality of care and good outcomes (specially in infant mortality rates),
the bureaucratic system contributed to the deterioration of users access to care
and professional dissatisfaction, among other problems
MEANWHILE…
DECENTRALIZATION EXPERIENCES IN PHC
Alfa Project (1996) - Objective: create a health team with autonomy to define their
organizational and delivery model, innovating in some aspects as the possibility of
making appointments by phone, home visits, bet in long term care and especially in
organizing the provision in small multidisciplinary teams to optimize resources and
improve performance. This experiment comprised 15 groups.
RRE groups (1998) - Experimental payment system - Objective: contribute to health
gains and increase users and professional satisfaction. Too integrate this system, doctors
should be part of a small group, with substitution and complementarities agreement. It
was mandatory to provide an annual action plan, users list database and an activity
monitoring system.
Test- tube (1999) – Objective: provision of primary health care to a total of 25 000 users,
without geographic limitation and compliance programs established by the Regional
Health Administrations.
Subsequent to some positive experiences in the 90’s, in 2005 began
probably the most innovative reform taking place in European PHC
context, combining a bottom up and a top down approach to manage
change and attain effective managerial decentralization
PHC REFORM:
• Guided
by health governance principles (inclusion, transparency,
accountability)
• Strong focus in improving healthcare access and quality
• Organizational philosophy based on the idea that public health
and community care services are part of an “umbrella” primary
care concept rooted in multi professional teamwork
The bottom up approach was designed to attract primary care
professionals to a “team practice model” with considerable organizational
autonomy. The top-down component is constituted by the definition of
national development strategies and establishment of 74 “primary care/
health centre groups”, as organizations capable of absorbing managerial
responsibilities from the regional health administrations, in order to
provide effective support to team practices, community care and public
health initiatives
New model
Ancient model
Regional Health
Administration
Regional Health
Administration
Transition
Sub regional
Health
Administration
HC
HC
HC
Dependence
Support
management
unit
Clinical
Governance
PHC
Groups
Health
strategies
Autonomy
WHY IS SO IMPORTANT FULLY IMPLEMENT THIS NEW
MODEL?
It’s known that development of PCH depends on the
ability and capacity of many of the decisions may be
taken at local level.
The PHC reform predicted the consolidation of
decentralization through the creation of PHC groups
with technical, managerial and financial autonomy.
Although, the lack of management autonomy is the
major structural transformation not yet implemented.
WHAT WE INTEND TO DO ?
Design a study (PhD thesis) with the aim of
identify the decentralization blocking factors, and
demonstrate the benefits of decentralization and
decision making at local level and its impact on
effective practices, quality of care, costs reduction
and health gains.
The propose is based on the need for an efficient, decentralized (to the local level)
management, with the recognition of the health needs of individuals, families and
communities;
with adapted and direct answers to specific cases, without relying on unnecessary
bureaucracy and power games that undermine the ultimate goal of the health
system:
providing quality health care to the population and contribute to health gains.
RESEARCH QUESTIONS
• What
is the perception of management autonomy
of the involved professionals (from Regional health
Administrations and PHC groups)?
• The PHC groups are endowed with autonomous
management?
• What degree of management autonomy (at the
local level), PHC groups have?
• What factors limit the implementation of
decentralization and management autonomy?
OBJECTIVES
• Analyze perceptions about management autonomy
at the local level, of professionals groups involved in
the decentralization process
• Achieve perceptions consensus about management
autonomy
• Identify the expectations of professional groups
involved in the decentralization process, as the
autonomy of local management
• Sort the current degree of management autonomy
• Identify limiting factors of the implementation of
decentralization and consolidation of management
autonomy
METHODOLOGY
• Literature review about perception of
management autonomy and the importance of
managerial autonomy for organizational
development of innovative models to provide
PHC
• Exploratory interviews
• Content Analysis
• Online survey in order to analyze the
perceptions of management autonomy,
professional expectations and degree of
management autonomy in PHC groups
• Statistical Analysis
•Delphi Panel
After
• Obtain consensus about perceptions of
autonomy and decentralization of
management
and
• Identified the factors that limit their
implementation
We intend to support a selected number
PHC groups concerning the adoption and
development of tools that facilitate the
management autonomy and
decentralization.
We will monitor the activity of these PHC
groups to evaluate the impact of
decentralization and management
autonomy in their performance, health
gains and health expenditure
If you have any comments, questions or suggestions
concerning this study or about primary health care in
Portugal, please feel free to contact us at
patbarbosa@ensp.unl.pt
Author: Patricia Barbosa
Graphic production: Filipe Rocha
National School of Public Health - NOVA University of Lisbon - Portugal