Primary health care in Portugal The need for an effective decentralization

1. Primary health care in Portugal The need for an effective decentralization Patrícia Barbosa NOVA University of Lisbon Portugal Gothenburg, 3rd and 4th Sept 2012

2. In the early 70’s Portugal was one of the first European countries adopting the concept of “Health Centres” HEALTH CENTRE

3. 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

4. Organizational structure of PHC between 70’s and 2005 Ministry of Health Regional Health Administrations (5) Sub-regional health administrations (18) Health extension Health extension Health extension Health extension Health Centre Health Centre Health extension Health Centre Health extension Health extension Health extension Health Centre Health Centre Health Centre Health Centre Health extension Health extension Health extension Health extension Health Centre Health extension Health extension Health extension

5. “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

6. 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

7. Meanwhile…Decentralization experiences in PHC

8. 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

9. 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 Ancientmodel Regional Health Administration Regional Health Administration Transition Support management unit Subregional Health Administration PHC Groups ClinicalGovernance Health strategies HC HC HC Dependence Autonomy

10. 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.

11. 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.

12. 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?

13. 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

14. 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

15. 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

16. 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 NationalSchoolof Public Health - NOVA University ofLisbon - Portugal