Published expertise

Take a look at our work


  • Campos-Matos, I., Alarcão, V., Lopes, E., Oiko, C. and Carreira, M. (Forthcoming) SAIMI Study – Health and health care Access by Immigrants from the Indian subcontinent in Lisbon: what recommendations for equitable and culturally adequate health care?. Accepted for publication in the Portuguese Medical Journal.
  • Castanheira, F. (Forthcoming). Perceived social impact, social worth and job performance: mediation by motivation. Journal of Organizational Behavior. DOI:10.1002/job.2056
  • Santos, A., Chambel, M.J., & Castanheira, F. (Forthcoming). Relational job characteristics and nurses’ affective commitment: the mediating role of work engagement. Journal of Advanced Nursing. DOI: 10.1111/jan.12834
  • Santos, J., Tavares, M., & Barros, P.P. (Forthcoming). More than just numbers: Suicide rates and the economic cycle in Portugal (1910-2013). SSM - Population Health.
  • Alves J, Nunes C, Perelman J. (2015). Socio-economic inequalities in tobacco-related diseases in Portugal: an ecological approach, Public Health, published online ahead-of-print, 29th September 2015.
  • Alves, J., Kunst, A. E., & Perelman, J. (2015). Evolution of socioeconomic inequalities in smoking: results from the Portuguese national health interview surveys. BMC Public Health, 15(1), 311. doi:10.1186/s12889-015-1664-y
  • Alves, J., Nunes, C., Perelman, J. (2015) Socio-economic inequalities in tobacco-related diseases in Portugal: an ecological approach. Public Health. doi: 10.1016/j.puhe.2015.08.008
  • Campos-Matos, I., Subramanian, S.V e Kawachi, I. (2015). "The ‘dark side’ of social capital: trust and self-rated health in European countries." The European Journal of Public Health (2015): ckv089. DOI:
  • Campos-Matos, I. $ Kawachi, I. (2015). " Social mobility and health in European countries: does welfare regime type matter?" Social Science & Medicine 142 (2015): 241-248. 
  • Castanheira, F., & Story, J. (2015). Making good things last longer: The role of savoring on the relationship between HRM and positive employee outcomes.Human Resource Management. DOI:10.1002/hrm.21704.
  • Chambel, M.J., Castanheira, F., & Sobral, F. (2015). Temporary agency versus permanent workers: A multigroup analysis of associations between human resource management, work engagement and affective commitment.Economic and Industrial Democracy. DOI: 10.1177/0143831X14550695
  • Chambel, M.J., Castanheira, F., Lopes, S., & Oliveira-Cruz, F. (2015). Work Context Support and Portuguese Soldiers' Well-being: The mediating role of autonomous motivation. Military Psychology, 27, 297-310. DOI:10.1037/mil0000087
  • Kuipers MA, de Korte R, Soto VE, Richter M, Moor I, Rimpela AH, Perelman J, Federico B, Kunst AE, Loran V. (2015). School smoking policies and educational inequalities in smoking behaviour of adolescents aged 14–17 years in Europe. Journal of Epidemiology and Community Health, published online ahead-of-print, 10th September 2015.
  • Laires PA, Perelman J, Consciência JG, Monteiro J, Branco JC. (2015). Epidemiology of hip fractures and its social and economic impact. An update for 2014. Acta Reumatológica Portuguesa 2015, 40:223-230.
  • Lopes, S., Chambel, M.J., Castanheira, F., & Oliveira-Cruz, F. (2015). Job Satisfaction among military workers: validation of the Job Descriptive Index in a Portuguese sample of military workers. Military Psychology,27, 52-63. DOI:10.1037/mil0000060.
  • Lorant V, Soto VE, Alves J, Federico B, Kinnunen J, Kuipers M, Moor I, Perelman J, Richter M, Rimpela A, Robert PO, Roscillo G, Kunst AE. (2015). Smoking in school-aged adolescents: design of a social network survey in six European countries. BMC Research Notes 2015, 8(1), 91.
  • Moureaux C, Perelman J, da Costa EM, Roch I, Annemans L, Heymans I, Closon M. C. (2015). Impact of the Medical Home Model on the Quality of Primary Care: The Belgian Experience. Medical Care 2015, 53(5):396-400.
  • Perelman J, Felix S, Santana R. (2015). The Great Recession in Portugal: Impact on hospital care use. Health Policy 2015, 119:307-315.
  • Perelman J. (2015). Liberdade de escolha no Serviço Nacional de Saúde – O caso do VIH. Acta Médica Portuguesa 2015, 28(2):138-140.
  • Cabral, L.; Russo, G.; Weinstock, J. (2014). Brazil and the shifting consensus on development cooperation. Salutary diversions from the ‘aid-effectiveness’ trail?. Development Policy Review. 32(2); 179-202.
  • Campos-Matos, I., Peralta-Santos, A., Gomes, B., Borges, G., and Aguiar, P. (2014). Body Mass Index Assessment of Health Care Professionals in a Primary Care Setting in Portugal: a Cross Sectional Study. Acta Med Port 2014 Sep-Oct;27(5):609-614
  • De Cuyper, N., Castanheira, F., De Witte, H., & Chambel, M.J. (2014). A multiple group analysis of associations between emotional exhaustion and supervisor-rated performance: Temporary versus permanent call center workers.Human Resource Management, 53(4), 623-633. DOI:10.002/hrm.21608
  • Goulão, C.; Perelman, J. (2014). The interaction between a public and a duplicate private provider of health services. In: Anthony J. Culyer (ed.), Encyclopedia of Health Economics, vol. 2, San Diego: Elsevier, 2014: 72-82.
  • Mendonça L, Perelman J, Rodrigues V, Fragata J. (2014). Cost-effectiveness of lung transplantation and its evolution: the Portuguese case. The European Journal of Health Economics 2014, 15:767-772.
  • Miraldo, M., Galizzi, M. M., Merla, A., Levaggi, R., Schulz, P.J., Auxilia, F., Castaldi, S. and Gelatti, U. (2014). Should I pay for your risky behaviours?: evidence from London. Preventive Medicine, 66. pp. 145-158. ISSN 0091-7435
  • Perelman J. (2014). Are chronic diseases related to height? Economics and Human Biology 2014,  15:56-66.
  • Wheelock A., Miraldo M., Parand A., Vincent C., Svedalis N. (2014). Journey to vaccination: a protocol for a multinational qualitative study. BMJ Open, 2014;4:e004279 doi:10.1136/bmjopen-2013-004279
  • Wheelock A., Parand A., Rigole B., Thomson A., Miraldo M., Vincent C., Sevdalis N. (2014). Socio-psychological factors driving adult vaccination: a qualitative study. PLoS One. 2014 Dec 9;9(12):e113503. doi: 10.1371/journal.pone.0113503
  • Alves, J.; Kunst, A.; Perelman, J. (2013). Evolution of socioeconomic inequality in smoking behavior in Portugal: 1987-2006: Joana Alves. European Journal of Public Health, 23(suppl_1), ckt126.304.
  • Alves, J.; Nunes, C.; Perelman, J. (2013). Creating a socioeconomic indicator for Portuguese parishes to measure inequalities in healthcare needs (among others): Joana Alves. European Journal of Public Health, 23 (suppl_1), ckt123.154.
  • Alves, J.; Peralta, S.; Perelman, J. (2013). Efficiency and equity consequences of decentralization in health: an economic perspective. Revista Portuguesa de Saúde Pública, 31(1), 74-83.
  • Barros, Pedro Pita (2013). Desafios do envelhecimento na Europa, com um olhar sobre Portugal. In Envelhecimento e Inovação Social, Lisboa, Fundação Calouste Gulbenkian.
  • Barros, Pedro Pita (2013). Saúde Mental e Economia – reflexões a propósito dos 50 anos do Serviço de Psiquiatria do Hospital de São João. In: A. R. Torres (Editor), Saúde Mental – modo de usar, Livro comemorativo dos Cinquenta Anos da Clínica de Psiquiatria e Saúde Mental do Centro Hospitalar São João, Porto.
  • Barros, Pedro Pita; Cardoso, Teodora; Esteves, Paulo; Pinheiro, Maximiano (2013). Conferência Para uma reforma abrangente da organização e gestão do sector público. In: Banco de Portugal, Conselho de Finanças Públicas e Fundação Calouste Gulbenkian (Editores), Para uma reforma abrangente da organização e gestão do sector público – Towards a Comprehensive Reform of Public Governance, Lisboa, pp. 21-33.
  • Barros, Pedro Pita; Clougherty, Joseph; Seldeslachts, Jo (2013). Europeanization of EU Member-State Competition Policy: The Commission’s Leadership Role. International Review of Law and Economics, Volume 34, Issue C.
  • Barros, Pedro Pita; Cristovão, Rita; Andrade Gomes, Pedro (2013). Portugal. In: Luigi Siciliani, Michael Borowitz and Valerie Moran (Editors), Waiting Time Policies in the Health Sector. What works?, OECD Book, Paris, France.
  • Barros, Pedro Pita; Gonçalves, Ricardo (2013). Economies of scale and scope in the provision of diagnostic techniques and therapeutic services in Portuguese hospitals. Applied Economics, 45, 415-433.
  • Barros, Pedro Pita; Gonçalves, Ricardo (2013). Economies of scale and scope in the provision of diagnostic techniques and therapeutic services in Portuguese hospitals. Applied Economics. Volume 45, Issue 4, pp. 415-433.
  • Camejo RR, McGrath C, Rutten F, Miraldo M. (2013). Distribution of health-related social surplus in pharmaceuticals: an estimation of consumer and producer surplus in the management of high blood lipids and COPD, Eur J Health Econ
  • Castanheira, F., & Chambel, M.J. (2013). The JD-C model to explain burnout in frontline workers: The useful contribute of emotional demands.Human Factors and Ergonomics in Manufacturing & Service Industries, 23(5), 412-423. DOI: 10.1002/hfm.20326.
  • Laranjeira, Erika; Borges, Ana Pinto (2013). The main determinants of the health status of the populations. Gac Sanit. 2013; 27 (Espec Congr 1).
  • Laranjeira, Erika; Borges, Ana Pinto (2013). What are the drivers of the overall increase in healthcare expenditures? A new look on technological innovation. Gac. Sanit. 2013; 27 (Espec Congr 1).
  • Laranjeira, Erika; Borges, Ana Pinto (2013). An essay about the misperception of public goods' costs and benefits. Lusophone Management and Administration Review, Vol. 1 (1), pp. 16–26.
  • Laranjeira, Erika; Borges, Ana Pinto; Cardoso, Cláudia (2013). Privacy and security aspects in ehealth at home under the implementation of Directive 2011/24/EU. International Conference on Technologies and Law, pp.76-84.
  • Laranjeira, Erika; Borges, Ana Pinto (2013). Why and how did health economics appear? Who were the main authors? What is the role of ITCs in its development?. In: Maria Manuela Cruz-Cunha, Patricia Gonçalves and Isabel Miranda (ed.), Handbook of Research on ICTs and Management Systems for Improving Efficiency in Healthcare and Social Care, IGI Global.
  • Perelman, J.; Roch, I.; Heymans, I.; Moureaux, C.; Lagasse, R.; Annemans, L.; Closon, M. C. (2013). Medical Homes Versus Individual Practice in Primary Care: Impact on Health Care Expenditures. Medical Care 2013, 51(8):682-688.
  • Perelman, J.; Alves, J.; Miranda, A. C.; Mateus, C.; Mansinho, K.; Antunes, F.; Oliveira, J., et al. (2013). Custos diretos com tratamento do VIH/SIDA em Portugal. Revista de Saúde Pública, 47(5), 865–872.
  • Refoios R, McGrath C, Miraldo M, et al. (2013). The Determinants of Cost-Effectiveness Potential: An Historical Perspective on Lipid-Lowering Therapies, Pharmacoeconomics, Vol:31, ISSN:1170
  • Russo, G.; Cabral, L. V.; Ferrinho, P. (2013). Brazil-Africa technical cooperation in health: what’s its relevance to the post-Busan debate on aid effectiveness. Globalization and Health. Jan 22; 9(1):2.
  • Russo, G.; McPake, B.; Fronteira, I; Ferrinho, P. (2013). Negotiating markets for health: an exploration of physicians’ engagement in dual practice in three African capital cities. Health Policy and Planning. doi:10.1093/heapol/czt071.
  • Russo, G.; Shankland, A. (2013). Brazil’s engagement in health cooperation; is there a contribution to the global debate on health? Health Policy and Planning. March, doi:10.1093/heapol/czt014.
  • Yazdanpanah, Y; Perelman, J; Dilorenzo, M; Alves, J; Barros, H.; Mateus, M.; Pereira, J.; Mansinho, K.; Robine, M.; Park, J.; Ross, E.; Losina, E.; Walensky, R.; Noubary, F.; Freedberg, K.; Paltiel, D. (2013). Routine HIV Screening in Portugal: Clinical Impact and Cost-Effectiveness. PloS ONE 2013, 8(12):e84173. 2012
  • Adesanya T, Gbolahan O, Ghannam O, Miraldo M, Patel B, Verma R, Wong H. (2012). Exploring the responsiveness of public and private hospitals in Lagos, Nigeria. Journal of Public Health Research. DOI: 10.4081/jphr.2012.e2
  • Barros, Pedro Pita (2012). Envelhecimento e despesas em cuidados de saúde. Cadernos de Economia, 98, pp. 33-35.
  • Barros, Pedro Pita (2012). Health Policy Reform in Tough Times. Health Policy, 106(1): 17-22.
  • Barros, Pedro Pita (2012). Novos desafios  em saúde e gestão hospitalar. In Conferências de Cascais – Saúde, Inovação e Desenvolvimento, HPP – Hospital de Cascais Dr. José de Almeida, Principia, pp. 21-29.
  • Barros, Pedro Pita (2012). Pharmaceutical market reforms in Portugal under the Memorandum of Understanding. Eurohealth, vol. 18(1): 33-36.
  • Barros, Pedro Pita (2012). Portugal’s Health Policy under a financial rescue plan. Eurohealth, Vol. 18(3): 10-13.
  • Barros, Pedro Pita (2012). Restrição Orçamental e Problemas Éticos na Prescrição. In Fundamentos Éticos nas prioridades em Saúde, Colecção Bioética 14, Conselho Nacional de Ética para as Ciências da Vida, Lisboa, pp. 57-78.
  • Barros, Pedro Pita; Siciliani, Luigi (2012). Public-private interface in health and health care. In Handbook of Health Economics, Volume 2, Editors: Mark Pauly, Thomas McGuire and Pedro P. Barros, Elsevier.
  • Chambel, M.J., & Castanheira, F. (2012). Training opportunities and employee exhaustion in call centres: The mediation by psychological contract fulfillment.International Journal of Training and Development,16(2), 107-117. DOI: 10.1111/j.1468-2419.2011.00394.x
  • Ferrinho F.; Amaral, M.; Russo, G.; Ferrinho, P. (2012). Purchasing power of civil servant health workers in Mozambique. The Pan African Medical Journal 11:14
  • Galizzi M, Miraldo M, Stravopoulou C, Desai M, Jayatunga W, Josh M, Parikh S. (2012). Who is More Likely to Use Doctor-Rating Websites, and Why? BMJ Open, 2012;2:e001493 doi:10.1136/bmjopen-2012-001493
  • Laranjeira, Erika; Borges, Ana Pinto (2012). Innovation in healthcare: it is sustainable?. Innovation for Sustainability – Is Your Responsibility, 1st International Conference on Innovation for Sustainability (IS2012), 2012, pp. 34-35, Lusíada University, Porto, Portugal.
  • Miraldo M, Siciliani L, Street A, (2012). Price adjustment in the hospital sector. A Reply, Journal of Health Economics, 2012, Vol:31.
  • Russo, G.; Ferrinho, P.; De Sousa, B. C.; Conceição, C. (2012). What influences national and foreign physicians’ geographical distribution? An analysis of medical doctors’ residence location in Portugal. BMC Human Resources for Health 10:12 doi:10.1186/1478-4491-10-12.
  • Barros, Pedro Pita (2011). Desafio: Melhorar o financiamento e a alocação de recursos no sistema. In Deloitte, editor, Saúde em análise – Uma visão para o futuro, Lisboa, Fevereiro de 2011, pp. 82-84.
  • Barros, Pedro Pita (2011). Enquadramento geral quanto a uma definição de “Mercado Ibérico”, com uma discussão sobre o sector eléctrico e energético. In: Mário Marques Mendes (Editor), Lisboa.
  • Barros, Pedro Pita (2011). Inovação e Sustentabilidade em Saúde – Equação Impossível? Cadernos de Saúde e Sociedade, n.º 1.
  • Barros, Pedro Pita (2011). Portugal: memorando de entendimento sobre políticas económicas e financeiras – Saúde. Brotéria, 173, 27-38.
  • Barros, Pedro Pita (2011). Sentado à conversa sobre o Novo Contrato Social da Saúde. In A Nova Saúde Pública – A saúde pública da era do conhecimento – Livro de Homenagem a Constantino Sakellarides, pp. 80-85. 
  • Barros, Pedro Pita (2011). The Simple Economics of Risk-Sharing Agreements between the NHS and the Pharmaceutical Industry. Health Economics, Vol. 20 (4), pages 461–470, April.
  • Barros, Pedro Pita; Machado, Sara Ribeirinho; Simões, Jorge (2011). Portugal: Health System Review. Health Systems in Transition, 13(4): 1-156.
  • Barros, Pedro Pita; Olivella, Pau (2011). Hospitals: teaming up. In The Oxford Handbook of Health Economics, edited by Sherry Glied and Peter Smith, Oxford University Press, Chapter 19, pp. 432-462.
  • Galizzi, M, Miraldo M, (2011). The effects of hospitals' governance on optimal contracts: Bargaining vs. contracting. Journal of Health Economics, Elsevier, vol. 30(2), pages 408-424, March.
  • Holly Alberto, Monfort Alain & Rockinger Michael (2011). Fourth order pseudo maximum likelihood methods. Journal of Econometrics, 162(2), 278-293. [doi] [web of science] [abstract]
  • McPake, B.; Hongoro, C.; Russo, G. (2011). Two-tier charging in Maputo Central Hospital: Costs, revenues and effects on equity of access to hospital services. BMC Health System Research, 11:143. doi:10.1186/1472-6963-11-143
  • Perelman J.; Closon, M. C. (2011). Impact of socio-economic factors on in-patient length of stay and consequences in per-case payment systems. Journal of Health Services Research and Policy 2011, 16(4): 197-202.
  • Barros, Pedro Pita (2010). A Saúde da Economia e a Economia da Saúde. Revista Portuguesa de Farmacoterapia, Volume 2, n.º 3, pp. 167-169.
  • Barros, Pedro Pita (2010). Pharmaceutical Policies in European Countries. In Advances in Health Economics and Health Services Research, Volume 22, edited by Avi Dor. Emerald.
  • Barros, Pedro Pita; Costa, Afonso Almeida (2010). Does a tougher competition policy reduce or promote investment?” Journal of Industry, Competition and Trade, May 2010. DOI: 10.1007/s10842-010-0076-z.
  • Barros, Pedro Pita; Machado, Sara Ribeirinho (2010). Money for nothing? The net costs of medical training. Health Care Management Science, Volume 13, Number 3, 234-255, DOI: 10.1007/s10729-010-9126-7.
  • Barros, Pedro Pita; Moreira Sara (2010). Double coverage and demand for health care: evidence from quantile regression. Health Economics, Volume 19, Issue 9, September 2010, pp. 1075-1092.
  • Barros, Pedro Pita; Nunes, Luis Catela (2010). The impact of pharmaceutical policy measures: a structural-break approach. Social Science & Medicine, Volume 71, Issue 3, August 2010, pp. 440-450.
  • Barros, Pedro Pita; Simões, Jorge; Temido, Marta (2010). Public-Private Partnerships in the Portuguese Health Sector. World Hospitals and Health Services, Volume 46(1):6-9. 2010.
  • Castanheira, F., & Chambel, M.J. (2010a).Burnout in salespeople: A Three-wave study to examine job characteristic’s predictions and consequences to performance.Economic and Industrial Democracy, 31(4), 409-429.DOI: 10.1177/0143831X10365573
  • Castanheira, F., & Chambel, M.J. (2010b).Reducing burnout in call centers through HR practices.Human Resource Management,49 (6), 1047-1065. DOI: 10.1002/hrm.20393
  • Galizzi MM, Ghislandi S, Miraldo M. Effects of Reference Pricing in Pharmaceutical Markets: a Review (2010). PharmacoEconomics, Vol.29, 2011
  • Fonseca F., Salgado S. and Brito C. (2010). Service Quality and Customer Satisfaction in Public Transports. International Journal for Quality Research, vol. 4, (2), pp.125-130.
  • Lamiraud Karine, Holly Alberto, Burnand Bernard, Juillerat Pascal, Wietlisbach Vincent, Froelich Florian et al. (2010). The effect of non-medical factors on variations in the performance of colonoscopy among different health care settings. Medical care, 48(2), 101-109. [doi] [web of science] [abstract]
  • Miraldo M, Siciliani L, Street A, (2010). Price adjustment in the hospital sector, Journal of Health Economics, Vol:30, Pages:112-125
  • Perelman, J.; Mateus, C.; Alexandre, A. (2010). Gender equity in treatment for cardiac heart disease in Portugal. Social Science and Medicine 2010, 71:25-29.
  • Russo, G.; McPake, B. (2010). Medicine prices in urban Mozambique. A public health and economic study of pharmaceutical markets and price determinants in low-income settings. Health Policy and Planning, 25 (1), 70-84.
  • Street A, Sivey P, Manson A, Miraldo M, Siciliani L (2010). Are Treatment Centres treating less complex patients?, Health Policy, Volume 94, Issue 2, Pages 150-157, February 2010
  • Tyrrell, A.; Russo, G.; Dussault, G.; Ferrinho, P. (2010). Costing the scaling up of human resources for health: lessons from Mozambique and Guinea Bissau. Human Resources for Health. 2010, 8:14.
  • Wirtz, V.; Russo, G. et al. (2010). Access to medicines by ambulatory health service users in Mexico: and analysis of the national health surveys 1994 to 2006. Salud Publica de México. Vol.52 (1), 30-38.


  • Barros, Pedro Pita; Fernandes, João Varandas (2012). Um ano depois da Troika na Politíca de saúde, Princípia.
  • Barros, Pedro Pita; Pauly, Marc; McGuire, Thomas (2012). Handbook of Health Economics, Volume 2, Elsevier-North Holland.

Working papers

  • Alves, Joana; Kunst, Anton; Perelman, Julian. Evolution of socioeconomic inequalities in smoking: Portugal 1987-2006.
  • Barros, Pedro Pita; Braun, Gisele. Upcoding in a NHS.
  • Barros, Pedro Pita; Martins, Bruno; Moura, Ana. The rocky road to market equilibrium – Price regulation in Portuguese retail pharmacy.
  • Braun, Gisele; Barros, Pedro Pita. Does it last? Effects from a public policy to recover waiting lists.
  • Fiorentino, Francesca; Barros, Pedro Pita. Hospital-acquired infections: a cost estimation for BSI in Portugal.
  • Moura, Ana; Barros, Pedro Pita. Entry liberalization and price competition: what can we learn from OTC products?.
  • Perelman, Julian; Felix, Sonia; Santana, Rui. Impact of economic and public debt crises on healthcare use in Portugal – hospital data, 2001-2012.

Theses & Dissertations

Research Grants

Funding body: FCT – Fundação para a Ciência e a Tecnologia 
Project reference: PTDC/ATP-GEO/4101/2012
Starting date: May 3, 2013
Duration in months: 24
Principal contractor: Universidade de Coimbra
Participating institutions: Centro Hospitalar de Lisboa Ocidental, EPE, Centro Hospitalar do Baixo Alentejo, EPE, Centro Hospitalar e Universitário de Coimbra, EPE, Escola Nacional de Saúde Pública – Universidade Nova de Lisboa, Nova School of Business and Economics, Hospital Distrital de Faro, Hospital Júlio de Matos, Hospital Magalhães Lemos, Hospital Professor Doutor Fernando Fonseca, EPE, Centro de Estudos de Geografia e Ordenamento do Território – Faculdade de Letras,, Universidade de Coimbra, Centro de Estudos de Doenças Crónicas – Faculdade de Ciências Médicas, Universidade Nova de Lisboa
Principal investigator: Paula Santana
Principal investigator at Nova School of Business and Economics: Pedro Pita Barros
Mental health is the complex result of multiple biological, psychological and social factors, also involving contextual factors beyond the individual. Empiric evidence suggests that certain characteristics of the environment may influence individual mental health beyond individual characteristics, i.e. the neighborhood/place effect. During the last decade, multilevel analyses have made possible to separate the individual effect from the neighborhood effect on health. The study of the associations between contextual socioeconomic status and mental health is a growing area of social epidemiology. Social environment varies widely across neighborhoods, along the dimensions of deprivation, residential stability (e.g., tenured housing and migration), family structure (e.g., living alone), social cohesion, quality of the built environment and ethnic composition. Furthermore, financial changes can be powerful determinants of health and economic crises are associated with mental disorders and mortality increase.
The National Psychiatric Survey-2009 has shown that Portugal is one of the European countries with a higher prevalence rate of mental disorders. The existing scientific evidence, mainly focused on treatment, supports cost-effective strategies to address this severe problem. There is, however, a lack of a deeper understanding on the impact of the residence local characteristics on mental health and mental disorders, particularly, during an economic crisis.
The goal of this project is to assess the effect of environmental and territorial health determinants on the mental health and on the use of mental health services in times of social and economic crises. This goal integrates specific objectives: 1 To study the associations between the evolution of contextual characteristics of a number of Portuguese municipalities in the last 10 years, and psychiatric morbidity and use of mental health services in these municipalities during the same period; 2 To understand how the mental health of individuals is affected by socioeconomic crises, depending on community support, social capital and urban planning; 3 To propose changes in the physical and social environment that may contribute, in periods of crisis, to promote mental health and reduce psychiatric morbidity of the populations.
The current study final recommendations will be aimed at orienting action, programs and policies with a possible impact on the negative effects on mental health and longevity of the more vulnerable groups to financial crises like the one we are currently experiencing in Portugal and in Europe.
To assess the evolution of the characteristics of the different places of residence we will consider groups of variables: measures of wealth in the municipality (economic activity, employment/unemployment, e.g.), community’s resources (green areas, social support networks, e.g.), accessibility to mental health care, level of safety (number of crimes, e.g.) and quality of lodging (overcrowded, e.g.).
Mental health of the populations will be assessed through: 1) Deaths by suicide (2010-2012, 2000-2002) by municipality; 2) Diagnosis Related Groups (DRGs) for mental disorders (2010-2012 and 2000-2002) by municipality; 3) Number and psychiatric diagnoses of all the catchment areas users with at least one contact (admission or outpatient psychiatric services) during 2012.
Information on 1) and 2) will be obtained through official sources (Serviço Nacional de Estatística and Administração Central do Sistema de Saúde) and will allow the calculation of standardized suicide rates and standardized residents with psychiatric admissions rates and the clusters identification of increased risk, before and during the financial crisis. Finally, information on 3) will be obtained by the medical charts review. Complementing this information, a representative sample of users and non-users (hospitals catchment areas population) will be surveyed with: a) A questionnaire aimed at assessing the relationship between the financial crisis consequences and changes on mental health perception and satisfaction with available resources in the place of residence; b) The Mental Health Inventory-5 to assess mental health perception. Mental health services utilization will be assessed with European Service Mapping Schedule.
Medical charts review will be submitted to the hospitals ethics committees before the start of the protocol. Confidentiality of all the information gathered and anonymization of the databases will be granted.
Therefore, and as already stated, as Mental Health is a multidimensional phenomenon linked to particular environments (places where individuals and groups interact), it requires a multivariate methodological approach, in the field of spatial epidemiology. Thus, after some descriptive approaches, correlation analysis, spatiotemporal clustering, risk areas, multivariate regression models and Geographical Information Systems will be used.

Funding body: FCT – Fundação para a Ciência e a Tecnologia
Project reference: PTDC/IIM-ECO/5165/2012
Starting date: April 1, 2013
Duration in months: 24
Principal investigator: Pedro Pita Barros
Public funding of health care is present in many countries and fiscal austerity characterizes the current times and near future of many European Union countries. The impact of fiscal austerity in the health and health care delivery will be a major issue in in the forthcoming years. This raises challenges in both empirical knowledge and theory. The need for measurement of impacts is clear in some areas, while in others practice is ahead of theory and development of conceptual frameworks is warranted.
The research project proposes to address these impacts in Portugal in three distinct areas: a) use of pharmaceutical products; b) use of hospital services; c) population ability to cope with catastrophic health expenditures. With this project we will produce evidence and arguments to assess and guide policy actions in the health care. We will address 5 themes in the above three areas.
Area a) use of pharmaceutical products
Theme 1: Structural changes in pharmaceutical expenditures in Portugal Pharmaceutical expenditures have grown considerably in Portugal over the last 20 years. The level of pharmaceutical expenditure has been a recurrent target of policies to contain health care costs. Previous works (Barros and Nunes, 2010 and 2011) found that most policies carried out have been largely ineffective in influencing the pace of pharmaceutical expenditures growth. These previous works addressed the first decade of the current century (2001-2010). We want to test the hypothesis of a structural break in the pharmaceutical sector, to identify which policies had the strongest impact, and whether impact was temporary or permanent.
Area b) use of hospital services
Theme 2: Effect of demand pressure on early discharges
Hospitals may react to random demand pressure by discharging patients earlier. The existence of resources constraints generates strong incentives to discharge patients earlier when demand is high. An early discharge, from a clinical point of view, increases the risk of readmission and decreases the benefit from treatment. Overall costs in the health system will be higher and inefficient decisions may be taken.
Theme 3: Use of hospital resources and proximity to death
The effect of population ageing in health expenditures is a much debated issue. The consensus is now that the important feature is proximity to death (Seshamani and Gray, 2004a, 2004b). We want to address this issue in Portuguese hospitals, to assess the impact of ageing in hospital costs, using as proxy the length of stay.
Theme 4: The efficiency of public-private partnerships as an instrument to deliver health care
The existence of pressure for lower public expenditures in the past has led to the search of new funding sources for public equipment. The use of public-privatepartnerships (PPP) was one of these new funding sources. It has come under close scrutiny from both theoretical and empirical viewpoints. Despite the widespread use of PPP in health care (see the report by DLA Piper) there is room for further discussion of two important theoretic aspects: 1) renegotiation of contracts, and 2) how health care providers interact in the (regulated) market for patients, as PPP hospitals and pure public hospitals face different sets of incentives. Technically, this calls for the conceptual framework to mix the delegation literature with mixed oligopoly literature.
Area c) population ability to cope with catastrophic health expenditures
Theme 5: Health expenditures and poverty risk, the role of catastrophic health expenditures
The financial protection against catastrophic health expenditures is receiving increased attention from the literature. Given the poverty level in Portugal, the current crisis may have implications to how well the population can cope with large health expenditures relative to their budget. The issue of financial protection in health was recognized as a challenge to health care systems in the last decade (WHO, 2007; Zu et al., 2007), and out-of-pocket payments are potentially large contributors to substantial drops in standards of living of populations. We address the issue with Portuguese data. The project will measure the evolution over time of the role of private, out-of-pocket, health expenditures in putting households at risk of poverty.
The data to perform the analysis comes from the surveys to household expenditures carried out by Statistics Portugal.

Funding body: WHO – European Center for Healthy Systems & Policies
Starting date: February 16, 2012
Duration in months: 24
Principal investigator: Pedro Pita Barros
Project title: The income gradient of lifestyles for the population aged 50+ in Portugal
Funding body: FCT – Fundação para a Ciência e a Tecnologia
Project reference: PTDC/EGE-ECO/121992/2010
Starting date: January 1, 2012
Duration in months: 24
Principal contractor: Nova School of Business and Economics
Principal investigator: Pedro Pita Barros
This project addresses the issue of inequalities and inequities in health care utilization in the population aged 50+. The elderly tend to be a more vulnerable population, and studies on inequities in health care use in Portugal focus on total population. Linked to existing inequities in the older population are the life-styles. We purport to identify the socio-economic determinants of smoking, drinking and exercising in the 50+ population. A final issue of interest is the health impact of the option to live alone by the elderly. This topic raises some methodological concerns, and needs to account for potential selection.

Funding body: Alto Comissariado da Saúde
Starting date: December 15, 2010
Principal investigator: Pedro Pita Barros
Project title: Share – Health, employment and retirement at 50+: Portugal
Funding body: European Commission
Starting date: December 1, 2009
Duration in months: 24
Principal investigator: Pedro Pita Barros

Other publications

A visão influencia a maneira como cada um se relaciona e se integra na sociedade. O acesso a cuidados de saúde da visão é desde há muito uma área passível de melhor intervenção do sistema de saúde. A pedido da Associação de Profissionais Licenciados de Optometria foi feito uma análise de quanto o objetivo de universalidade de cobertura se encontra cumprido, e de uma reflexão sobre os caminhos possíveis para melhorar a atual situação. Sugerimos dois planos de atuação: ao nível da cobertura financeira, dirigida a grupos mais vulneráveis e com mecanismos de verificação, de lentes e armações e ao nível do funcionamento dos cuidados de saúde primários, conjugando três princípios usualmente defendidos para o bom funcionamento do sistema de saúde: centralidade dos cuidados de saúde primários como primeiro ponto de contacto dos cidadãos, continuidade de cuidados e reforço da qualidade dos cuidados prestados. O trabalho pode ser consultado aqui na integra.