Social Equity Initiative

Promote research to create more value in the health care sector

BPI | "la Caixa" Foundation Chair in Health Economics

The BPI | "la Caixa" Foundation Chair in Health Economics aims to promote research and discussions in the health care area. The Chair is part of the Social Equity Initiative, launched in 2019 by the "la Caixa" Foundation, BPI, and Nova SBE, and intends to create more value for our country's health care sector. It also aims to contribute to a better understanding of Portuguese society and its relation with the health care system and discuss health-focused policies. It will allow the continuation of analyzing new trends and challenges, either through independent impact assessments or analysis to enable a better response by the health system and its policymakers to the population's needs and expectations.

It was awarded to Pedro Pita Barros, Professor of Economics at Nova SBE and Coordinator of the Nova SBE Health Economics & Management Knowledge Center, as a recognition of the work carried out in the ​​Health Economics area and evidenced by his participation in the European Union's Expert Panel on Effective Ways of Investing in Health, as well the work carried in the Mission Board for Cancer,  the National Health Council, and the National Council of Ethics for the Life Sciences.

 

Health Spending Observatory

The Health Spending Observatory intends to provide regular analysis on the dynamics of health spending in Portugal. This includes the analysis of the State Budget, financial arrears, and financing sources of the health system, among others. This publication analyses the economic challenges posed by population ageing, particularly regarding the management of retirement pensions and private savings for retirement. Long-term savings are crucial for individuals to protect themselves against the risks that increased longevity brings, such as the need to cover unexpected out-of-pocket health expenditures resulting from costly acute episodes or ongoing health expenditures associated with the worsening of chronic diseases. In Portugal, however, the wealth of older individuals is mainly tied up in illiquid assets like housing, which limits their ability to meet unexpected health expenditures. Adults aged 50 and over in Portugal exhibit a high aversion to financial risk and a very short-term savings planning horizon, partly due to low financial literacy. This short report highlights the urgent need for better financial planning and literacy to help individuals manage the risks posed by increased longevity and secure their financial future in retirement.

See report in portuguese.

The Health Spending Observatory intends to provide regular analysis on the dynamics of health spending. This includes the analysis of the State Budget, financial arrears, and financing sources of the health system, among others. This policy brief investigates current health expenditure in Guinea-Bissau - a country with which Portugal cooperates in various fields, through bilateral and multilateral agreements, to combat poverty and promote sustainable development. At the beginning of the 21st century, public domestic expenditure was the largest component of current health expenditure in Guinea-Bissau (46.68%). However, in 2010 there was a sharp decrease in domestic public current health expenditure per capita (a reduction of 60.76%), partly due to political instability. The reduction in public spending on health translated into an increase in direct household spending on healthcare. This, in turn, contributed to an increase in the percentage of the population placed in extreme poverty due to health spending. Despite the reduction in domestic public spending on health in Guinea-Bissau over the last two decades, universal health coverage has increased, partly due to the collaboration of external donors.

See report in Portuguese

The Health Spending Observatory intends to provide regular analysis on the dynamics of health spending in Portugal. This includes the analysis of the State Budget, financial arrears, and financing sources of the health system, among others. This policy brief investigates the forecasts of the 2024 State Budget for the Health sector. The Budget for 2024 increases the public health expenditure by 5,3% in nominal terms, relative to the budget execution estimate for 2023. However, more than half of that increase is related with price effects and the share of health spending in public expenditure decreases to 12,9%. The current forecasts for human resources expenditures and goods and services purchases may not be enough to meet existing needs. Unless credible mechanisms are implemented to penalize problems (inefficiencies) in management practices, it is not clear that the generalization of Local Health Units, which are financed through capitation payments, will result in greater budgetary control.

See report in portuguese

The Health Spending Observatory intends to provide regular analysis on the dynamics of health spending in Portugal. This includes the analysis of the State Budget, financial arrears, and financing sources of the health system, among others. This publication analyses health expenditure in community pharmacies in Portugal. The weight of direct household payments in community pharmacies rose from 39% in 2000 to 45% in 2020. This increase reflects the 'insignificant' weight of health insurance and health subsystems in health expenditure in community pharmacies and reveals the potential reduction in financial protection of the population. NHS expenditure accounted for around 49%. Between 2003 and 2022, the number of packages dispensed increased by 40%, signalling a progressive increase in demand for medicines. Over the analysed period, the increase in consumption contributed to a 37% increase in the cost of medicines. Conversely, the reduction in prices during this period contributed to a 16% reduction in costs. Thus, the combination of these two effects resulted in an increase in costs of 21%.

See report in portuguese.

The Health Spending Observatory intends to provide regular analysis on the dynamics of health spending in Portugal. This includes the analysis of the State Budget, financial arrears, and financing sources of the health system, among others. This report investigates the relevance of direct payments by households in the financing of the Portuguese health system. Approximately 29% of health spending is directly financed by Portuguese households at the moment of healthcare provision. Most direct payments are associated with the use of private outpatient care and the purchase of medicines in community pharmacies. Direct payments put greater pressure on lower income households and constitute a potential barrier to access. Attempts to improve healthcare access through a reduction in direct payments by households should mainly target the reimbursement of medicines and access to outpatient care, in particular oral health for economically deprived households.

See report in Portuguese

The Health Spending Observatory intends to provide regular analysis on the dynamics of health spending in Portugal. This includes the analysis of the State Budget, financial arrears, and financing sources of the health system, among others.

This report investigates the relation between private health insurance and the National Health Service (NHS). Despite the significant growth over the last decades, private health insurance represents only 4% of overall health spending. Moreover, the growth of private health systems seems independent from NHS expenditures: the growth of private insurance does not seem related with any crowding-out of public expenditures. Instead, a significant share of the growth of private health insurance is explained by a reduction of the health subsystems.

See report in Portuguese.

The Health Spending Observatory intends to provide regular analysis on the dynamics of health spending in Portugal. This includes the analysis of the State Budget, financial arrears, and financing sources of the health system, among others. This policy brief investigates the forecasts of the 2023 State Budget for the Health sector. The Budget for 2023 increases the share of health spending in public expenditures to its highest value in the last decade. However, a significant part of such increase is related with price effects – a major increase in health care provision is not expected. The current forecasts for human resources expenditures and goods and services purchases may not be enough to meet existing needs. A reduction in capital expenditures relative to its budget may be used to finance budget overruns in human resources and goods and services expenditures.

See report in Portuguese

Short notes: Analysis of the Health Sector

The Short Notes series intends to provide analyses on key topics related with the health sector. This Short Note provides an overview of chronic disease management in European health systems, emphasising the diversity of existing models and their key elements. The review of different approaches to chronic disease management emphasises the absence of a single model. This diversity reflects the complex nature of chronic conditions and the responses required to meet the varied needs of patients and the capacities of health systems. There is a growing focus on the role of patient self-management and the digital transformation of health, which reflect the changing paradigms in healthcare. International experience highlights the importance of the context of each health system in defining the best chronic disease management model. A central element of success is the coherence between the organisational and financial elements used in the chronic disease management model.

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The Short Notes series intends to provide analyses on key topics related with the health sector. This Short Note analyses an innovative solution, within the scope of the Portuguese National Health Service, in response to the shortage of family doctors and its impact on access to healthcare. Via Verde Saúde (VVS) is a temporary measure designed to provide primary healthcare services to the most disadvantaged population in the Lisbon area without a family doctor. The creation of VVS was based on a new model of primary healthcare that relies on a multidisciplinary team approach. This Short Note evaluates VVS along three main dimensions: professional satisfaction, patient satisfaction and economic and financial implications. The results show a high level of professional satisfaction and appreciation for the quality of the services provided. In terms of economic impact, the analysis indicates that maintaining VVS, with increased funding and a transition to a more sustainable model, would be less costly in budgetary terms than closing it, considering the potential increase in the costs of hospital emergency services due to lack of access to primary healthcare.

See report in Portuguese

The Short Notes series intends to provide analyses on key topics related with the health sector. Based on a survey of the population living in mainland Portugal, which is carried out since 2013 by the Nova School of Business and Economics, this short note analyses children's access to health care. The access reported by respondents from households with children and young people under the age of 15 was used as a proxy for children's access to healthcare, given that children’s access to care depends on household income. Compared to respondents from households consisting only of adults or working age individuals, respondents from households with children under 15 do not appear to face increased financial barriers in accessing healthcare. However, children from the lowest-income households face higher financial barriers in access to health care. Mitigating barriers to children's access to health care involves fighting against poverty – a concern and a need for intervention that goes beyond the health sector.

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The Short Notes series intends to provide analysis on key topics related with the health sector. This fifth short note explores the conceptual and methodological challenges associated with measuring unmet health care needs.  In 2019, around 40% of Portuguese people with health needs had at least one situation in which they were unable to access healthcare, a figure substantially higher than the European average of 26%, which puts Portugal in an unfavourable position compared to other European countries. The lack of access to healthcare in Portugal is mainly due to financial difficulties, with access to oral health and mental health care being particularly problematic.

See report in Portuguese.

The Short Notes series intends to provide analysis on key topics related with the health sector. This fourth short note investigates the individual use of contact tracing apps in the context of the COVID-19 pandemic, based on data collected from an European survey since the beginning of the pandemic. Within the countries included in this study, Portugal displays the lowest rate of download and utilization of such apps during the pandemic. In this short note we discuss three potential channels that affect the success of these apps: the technological landscapes and apps’ features, the individual adherence of each citizen, and the ability to achieve a minimum scale to induce a network effect.

See report in Portuguese

The Short Notes series intends to provide analysis on key topics related with the health sector.

See report in Portuguese.

 

The Short Notes series intends to provide analysis on key topics related with the health sector. This second short note investigates the evolution of public opinion support for restrictive measures implemented in the context of the COVID-19 pandemic, based on data collected from an European survey since the beginning of the pandemic. Noticeable differences in public opinion support are identified across the seven countries included in the survey. Data suggests that risk perception influences public opinion support for more restrictive measures. Nonetheless, the overall support for restrictive measures in Portugal has been declining over time.

See report in Portuguese.

The Short Notes series intends to provide analysis on key topics related with the health sector. This first short note investigates the evolution of trust on government’s information, based on data collected from an European survey since the beginning of the pandemic. Noticeable differences in the trust level are identified across time and across the seven countries included in the survey. More recent data, relative to the beginning of this year, places Portugal as the country with the highest level of trust on government’s information. Moreover, differences can also be identified across age groups. 

See report in Portuguese. 

Book

Title: Inovação em Saúde por quem a Pratica
Authors: Filipa Breia da Fonseca, Pedro Pita Barros, António Bensabat Rendas
Publisher: Almedina
Collection: Olhares Sobre a Saúde
Year: 2022
ISBN: 9789894002918
Pages: 160

Reports

The Ageing Report analyzes the current and future impact of population ageing on health expenditure and the elderly population's access to healthcare. It evaluates six key dimensions: the impact of ageing on health expenditure; financial protection in old age; access to healthcare for the elderly; active ageing; retirement and healthcare access; and the loneliness pandemic.

Given the profound economic and social implications of population ageing, addressing these challenges demands a concerted effort from health and social protection systems, along with various societal stakeholders. Strengthening social responses to combat elderly poverty and implementing initiatives that promote active ageing are crucial for managing the anticipated increase in the Portuguese population aged 60 and above.

See report in Portuguese

Population's access to healthcare is one of the central objectives of health systems. This report focuses on assessing this access for households with children (under 15) in mainland Portugal. Based on survey data collected since 2013 by the Nova School of Business and Economics, the access of these households is analysed in comparison to households composed only of adults or of working-age people.

Various dimensions of access are explored, including the decision to seek healthcare in the event of an illness, as well as the existence of financial and non-financial barriers. The results show that, when characteristics such as socioeconomic status are considered, households with children do not show significant differences in access to healthcare compared to other households. However, there is a clear socio-economic gradient, indicating that households in more disadvantaged groups are more likely to face barriers to accessing healthcare, regardless of the presence of children in the household.

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Access to healthcare is among the main concerns of the population regarding health systems functioning and performance. The COVID-19 pandemic has disrupted health systems, with consequences in terms of access to healthcare as well. Based on an annual survey, this report displays the evolution of health care access in Portugal, with a particular focus on the years of 2020 to 2022. Together with past editions, it is possible to analyse key trends since 2013. This report details multiple dimensions of health care access, including disease incidence, the decision to look for health care, access barriers (financial and non-financial), and the public vs private health care provision.

See report in Portuguese.

Human Resources in the Health Care sector are considered the backbone of Health Systems. The discussion regarding health systems’ challenges implies an analysis of the role that human resources have in the health system. This report presents a set of analysis on multiple challenges affecting health professionals in the Portuguese health system, particularly physicians and nurses. Multiple factors that may contribute to the difficulty on attracting and retaining professionals are discussed in the report. This includes analysis on health professionals ageing, income, dual practice, migration, training capabilities, among others.

Additionally, a discussion on task-shifting and skill-mix is also included to discuss its implications in the Portuguese Health System.

See report in Portuguese.

Access to Health Care – Citizens' Choices

Why?
Portuguese society's values on access to health care services are underlined in the Portuguese Constitution and Lei de Bases da Saúde [Health Basic Law]. Little is known about citizens and their decisions on when and how they contact the health care system when they feel sick and before starting their journey within the national health system (in the public or private sector).

How?
Through a population survey with a representative sample of 1271 inhabitants in Portugal over 15. It was the chosen way to learn more about what goes on under the radar of the health system and is not on the National Health Service's record. The GfK company carried out data collection.

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What did we learn?

  • There are socioeconomic inequalities when an illness occurs, but there is uniformity when accessing the health care system. Access conditions to the health care system do not enhance these inequalities. The decision to first contact the health care system displays very few obstacles regarding access. When accessing the health care system, impediments are not systematically associated with socioeconomic status within the collected sample (vulnerable populations not captured by these surveys indeed have specific problems). Difficulties occur in case of illness and are not related to health care conditions. From a citizen's perspective, access to the health care system improved, generally, from 2015 to 2020.
  • Self-medication is predominant in those who decide not to reach the health care system. Nevertheless, some citizens choose not to go to the health care system when feeling sick (about 10 %), regardless of their socioeconomic status. Of the sample, 63 % chooses to self-medicate. It is essential to learn how and the consequences that it entails.
  • There was no "escaping" from the National Health Service to the private sector, nor was the private sector abandoned. There was a reconfiguration within each. When choosing first to contact the health care system, the National Health Service is the leading choice of all socioeconomic groups. The private sector option is clustered in higher socioeconomic classes. Circa 7,3% of those who feel sick have this choice. This proportion rises to 15 % if someone has a higher socioeconomic status.
  • In 2020, the "escape" was from hospital emergencies, public and private, to another point of contact of the same industry. The number of people who mentioned a hospital emergency as their first contact with the health care system dropped from 41,1 % in 2019 to 32,2% in 2020 in the public sector and fell from 5 % to 2,1 % in the private sector.
  • The main financial difficulties in accessing health care services are associated with medical costs, even though there have been substantial improvements in recent years. The number of people who stopped buying the medical supplies they should, at least once a year, from 2017 to 2020, went from 10,7 % to 5,4 %. However, there are relevant socioeconomic inequalities. This amounted to 2 % in those two years for higher socioeconomic classes and rose from 11 % to 15 % for lower socioeconomic classes. Even though with lower numbers, a similar evolution emerged under the pretext of "not going to an appointment or doing a medical exam due to lack of money" (from 7 % in 2017 to 10 % in 2019 in lower socioeconomic classes).
  • For those who opt for the National Health Service when they have an unexpected illness, the main expense is the co-payment of prescribed drugs (average prices range from 21€ on prescriptions to 25€ total for a specific treatment, including user fees and transport, regarding primary health care services. When there is a hospital emergency, expenses amount to 24€ in prescriptions and 36€ total).
  • In 2020, there are two new "access obstacles" – the fear of reaching out to the health care system due to COVID-19, which was referred by 15 % of people, and having the health service provider cancel the appointment at his own initiative, referred to by 20 % of the people interviewed. Older people and people with lower socioeconomic status stated to have more fear. Cancellations under the provider's initiative affected all socioeconomic classes equally. The elderly, who usually have more medical appointments, were the ones who were more affected. Despite the fear, people still trust health care services (those who were more isolated during the pandemic are no longer afraid of going to the health care system).
  • Three out of four people feel they have been treated with dignity, compassion, and respect by the health care system's services. Even though there is a global number of 76,6%, in 2020, people who mentioned that they were treated with dignity, compassion, and respect, there were differences in said treatment associated with their level of education – 80% of people with basic levels of education to 72 % with higher education. Similar assessments in England show numbers ​​above 80 % and close to 90 % regarding specific health services.

 

What needs to get better?

  • Get to know the self-medication of those who do not seek the health system better
  • Improve the financial protection in medicine consumption
  • Improve the human aspect of the health care system's provision
  • Consolidate the primary health care response and its planned use

Research

  • Risk communication during COVID-19: A descriptive study on familiarity with, adherence to and trust in the WHO preventive measures, Nirosha Elsem Varghese, Iryna Sabat, Sebastian Neumann-Böhme, Jonas Schreyögg, Tom Stargardt, Aleksandra Torbica, Job van Exel, Pedro Pita Barros, Werner Brouwer, Plos one 16 (4), e0250872
  • Blood donation in times of crisis: Early insight into the impact of COVID‐19 on blood donors and their motivation to donate across European countries, Torsten Chandler, Sebastian Neumann‐Böhme, Iryna Sabat, Pedro Pita Barros, Werner Brouwer, Job van Exel, Jonas Schreyögg, Aleksandra Torbica, Tom Stargardt, Vox Sanguinis
  • The Financial Sustainability of the Portuguese Health System, E Costa, R Santos, PP Barros, The Sustainability of Health Care Systems in Europe
  • Simplified Mathematical Modelling of Uncertainty: Cost-Effectiveness of COVID-19 Vaccines in Spain, Julio Emilio Marco-Franco, Pedro Pita-Barros, Silvia González-de-Julián, Iryna Sabat, David Vivas-Consuelo, Mathematics 9 (5), 566
  • COVID-19, Fake News, and Vaccines: Should Regulation Be Implemented?, Julio Emilio Marco-Franco, Pedro Pita-Barros, David Vivas-Orts, Silvia González-de-Julián, David Vivas-Consuelo, International Journal of Environmental Research and Public Health 18 (2), 744
  • Concerns and adjustments: How the Portuguese population met COVID-19, S Valente de Almeida, E Costa, FV Lopes, JV Santos, P Pita Barros, PloS one 15 (10), e0240500
  • Battling the infodemics: health communication effectiveness during COVID-19, I Sabat, NE Varghese, S Neuman-Böhme, PP Barros, W Brouwer, J van Exel, J Schreyögg, T Stargardt, European Journal of Public Health 30 (Supplement_5), ckaa166. 072
  • Countering COVID-19: A European survey on acceptability of and commitment to preventive measures, I Sabat, N Elsem Varghese, S Neuman-Böhme, P Pita Barros, W Brouwer, J van Exel, J Schreyögg, T Stargardt, European Journal of Public Health 30 (Supplement_5), ckaa166. 619
  • United but divided: Policy responses and people's perceptions in the EU during the COVID-19 outbreak, Iryna Sabat, Sebastian Neuman-Böhme, Nirosha Elsem Varghese, Pedro Pita Barros, Werner Brouwer, Job van Exel, Jonas Schreyögg, Tom Stargardt, Health Policy 124 (9), 909-918