«The management of health systems in the EU Member States - The role of local and regional authorities The study was written by Progress Consulting ...»
Delivery of the services Health care services are provided through primary health care centres, specialised health units and hospitals. Primary care is provided through the USFs. As of April 2010 there were 420 USFs: these are self-organised multidisciplinary teams, including general practitioners, selected through public tender procedure and operating on a contractbasis, the contract being with the respective RHA.
Secondary in-patient and outpatient care is mainly provided in hospitals.
Hospital emergency units are also approached directly by patients and not necessarily for emergency care, thus general practitioners do not play a systematic gate-keeping role. As of 2005, there were 111 public hospitals and 93 private units. Hospitals may be public or private, and the latter may be for-profit or not-for-profit. Public hospitals belong to the State; their management may be given to private actors on a contractual basis.18 Hospitals based on public-private partnerships are becoming common.
The private sector (profit and non-profit) operates admission units, medical consultation rooms, diagnosis and therapeutic centres, a network of ambulances and of pharmacies. Private providers may have contracts with the national health system or with other sub-systems to provide care services.
INFARMED, accountable to the Ministry of Health, is the health authority dealing with the evaluation, authorisation, inspection and production control, distribution, commercialisation and use of medicines.
HOPE online country profile – Portugal: latest information from 2007
Finance and health care expenditure The public health system is mainly financed through general taxation, mostly (60%) from indirect taxes. In 2005, public health expenditure from general taxation represented 71.9% of total health expenditure. Private expenditure accounted for 26.1% of total expenditure in 2005 (22.3% from upfront payments and 3.8% from private insurance).
The Ministry of Finance allocates funds to the Ministry of Health that, in turn, allocates budgets to the RHAs which use these funds for primary health care centres. Hospitals are remunerated directly by the Ministry of Health on the basis of contracts. Public and private health sub-systems are funded through employer and employee contributions; they account for some 9% of total health expenditure. Both public and private financing arrangements imply cost-sharing which represents a significant share of total health expenditure (29% in 2004).
- Pita Barros P. and de Almeida Simões J. (2007), Health Systems in Transition, Vol. 9 No.5, Portugal Health system review, European Observatory on Health Systems and Policies
- Ribeiro Mendes F. (2010), Annual National Report 2010 – Pensions, Health and Longterm Care: Portugal. ASISP: Analytical support on the Socio-Economic Impact of Social Protection Reforms.
ROMANIA Main characteristics of the Romanian health care system ► Mostly centralised but under a decentralisation process, especially with regard to hospital facilities, with some responsibilities held by local authorities (district councils) ►Providing universal coverage free of charge at the point of service ► Mainly public financing of health care – contributions from national insurance system and general taxation at national and, to a lesser extent, district level ►Mainly public service provision Structure of the system At the central level, the Ministry of Public Health is responsible for developing policies, defining the legal framework and issuing regulations (including for the pharmaceutical sector), setting the operational standards, monitoring and evaluating health care provision and the organisation of health care providers. It is represented at the district level by 42 district public health authorities (DPHAs), one for each of the 41 districts and one for Bucharest.
The National Health Insurance House is the autonomous public institution administering and regulating the National Health Insurance Fund (NHIF), and responsible, in particular, for deciding on the benefits package and on the resources allocated across districts (through 42 District Health Insurance Funds DHIFs) and types of care, and for drawing up the yearly framework contract on the basis of which services from public and private providers are contracted.
Local authorities (district councils) are responsible for providing the framework conditions for the delivery of services of public interest, among which is health care, and for deciding on local budget and taxes. Since 2002, they have also been the owners of almost all public health care facilities. Even if theoretically they could play a significant role, their input is minor due to constraints in financial and human resources. At district level, provision of health care is in fact controlled and organised by DPHAs, with DHIFs playing a major role in the contracting of service providers (in fact, DPHAs manage less than one third of the available public budget, the rest being managed by DHIFs).
The district council nominates one of the members of the Council of Administration leading each DHIF.
Delivery of services The mandatory health insurance scheme introduced in 1998 covers the whole population. Health insurance gives access to a basic benefits package that includes, among other things, health care services (ambulatory care, hospital care, and emergency services), pharmaceuticals, dentistry services, and rehabilitation.
Almost all health providers are independent practitioners contracted by DHIFs. Primary health care services are provided through family doctors. Ambulatory secondary care is delivered through a network of outpatient departments within hospitals, centres for diagnosis and treatment, and specialists. In 2009, due to evidence of unsatisfactory management of hospitals, a decentralisation process of 373 hospitals (out of a total of 435) was begun; decentralised hospitals will be funded through state and local budgets as well as from the NHIF. Local authorities will nominate the hospital management and finance administrative expenses.
People may choose their provider freely; access to secondary care in hospitals needs a referral from the family doctor, with the exception of emergencies.
Finance and health care expenditure The major funding source of health care is from contributions paid by the insured totalling almost 83% in 2004 (estimated at 75% in 2007); there are several categories exempted from this payment, including, for example, the dependants of the insured, the unemployed, those on military service or those aged under 18. In 2010, employed people contributed 10.7% of their payroll (5.5% paid by the employees and 5.2% by the employers). Taxes represent the second most important source of revenue for health expenditure: in 2004, these contributions amounted to 15.8% of the total, of which 14.4% came from general taxes and 1.4% from local taxes.
Upfront payments refer to co-payments for services included in the benefits package or to direct payments for services purchased directly from private providers. There is no recent estimate of such payments; in 1996 they were considered to account for 29% of total health expenditure, while in 2002 WHO data stated the figure was 34%. In April 2010 a new co-payment mechanism called the ‘health ticket’ was introduced, defining a contribution rate per type of service (for example, contributions for medicines may vary from 0% to 50% of the reference price); exemptions from the payment of contributions apply.
- Vladescu C. et al. (2008), Health Systems in Transition, Vol. 10 No.3, Romania: Health system review, European Observatory on Health Systems and Policies
- Zaman C. (2010), Annual National Report 2010 – Pensions, Health and Long-term Care:
Romania. ASISP: Analytical support on the Socio-Economic Impact of Social Protection Reforms.
Main characteristics of the Slovak health care system ►Partially decentralised, with some responsibilities held by regional authorities (self-governing regions) and municipalities with respect to secondary and primary care facilities, respectively ►Providing universal coverage mostly free of charge at the point of service through a mandatory health insurance system ►Mainly public financing of health care – contributions from the insurance system ►Mixed service provision – public and private Structure of the system At central government level, the Ministry of Health is responsible for policy and regulation of the health care, including pricing; it also manages national health programmes, determines quality criteria and the scope of the benefits package to be provided to insured people. Finally, it is the owner of care facilities and of one of the three existing insurance companies.
The Ministry of Labour, Social Affairs and Family is responsible for social care, a circumstance that has led to the two systems developing separately. Other Ministries such as, for example, the Ministry of Finance which is responsible for budgeting, are involved in other health-related aspects.
The Health Care Surveillance Authority (HCSA) was established in 2004 to overcome obvious conflicts of interest. HCSA supervises health insurance, the purchasing and provision of service market, and the risk adjustment mechanism for redistributing contributions collected with the insurance schemes. Various central authorities and bodies oversee other health-related tasks.
Some tasks have been decentralised to the eight selfgoverning regions in particular with regard to monitoring, issuing of permits to providers, and securing health care provision in specific circumstances, such as the temporary withdrawal of a provider or upon detection of poor accessibility of services by patients – then, in the latter case, they can directly appoint physicians to overcome the shortage. Based on evidence provided, they can ban a provider from the market, but only upon recommendation of the HCSA. Additionally, the central government has to approve the ‘Chief Physician’ of each self-governing region. Regions also own and independently manage, and often invest in, some health care facilities. Ownership of facilities was transferred in 2003: selfgoverning regions received the so called ‘type II’ hospitals providing secondary care, while ‘type I’ hospitals with facilities for primary care were devolved to municipalities. Coordination between the central government and the self-governing regions is not always smooth. Additionally, self-governing regions and municipalities are also involved in the financing of social care through their respective budgets.
The central government has retained the ownership of the largest and highly specialised structures, often in the form of ‘contributory organisations’, i.e.
entities where government authorities are not the only funding sources and revenues from other sources are possible. Health departments within other ministries than the Ministry of Health manage health facilities of their own.
Pharmacies and diagnostic laboratories and the majority (90%) of outpatient facilities are private.
A key role in the system is played by the three health insurance companies, as they purchase the services they are obliged to deliver to the insured according to a benefits package determined by law. One of these companies provides mandatory insurance is provided to the population, these earlier health insurance funds were public institutions and have been profit-making joint stock companies since 2005. The Ministry of Health owns the largest of the three, which had a market share of 68% in 2010, while the other two are private. These companies are subject to managed competition. Providers may be public, private, non-profit or contributory organisations; all but 39 state hospitals, considered fundamental to the maintenance of a fair geographical distribution of services, compete to win contracts on the basis of quality criteria and prices.
Delivery of services Patients may freely choose their general practitioner or specialist professional, but apart from general practitioners, all other providers have to be contracted by the insurance companies. Service provision does not require co-payments, with a few exceptions, such as dental care. Ambulatory care is provided through general practice, one-day surgery or outpatient departments in polyclinics. Secondary care is provided in general hospitals (including university hospitals) and specialised hospitals, owned publicly or privately. Secondary care requires a referral from a GP or a specialist (gate-keeping system). Emergency care services are provided by private or public provider, while pharmacies and drug distributors are almost all private.
Finance and health care expenditure Contributions collected through health insurance payments represent the main source of funding of the public system. Contributors include the employed population, the voluntarily unemployed and non-employed people, for whom the state pays contributions. A governmental financing system also exists, based on general taxation at the national, regional and municipal levels. Private contributions are from user charges and co-payments from patients. Voluntary insurance schemes are not usually undertaken. In 2007, public sector expenditure was 76.5% of total health expenditure, the rest being privately sourced through private revenues. Private expenditure is rising mostly because of higher expenditure on medicines.
Szalay T. et al. (2011), Slovakia: Health system review. Health Systems in Transition, 2011;
13(2):1–200, European Observatory on Health Systems and Policies.