Momentos económicos… e não só

About economics in general, health economics most of the time

Assessment of implementation of Troika measures in the health sector

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I provide below my assessment of the progress of the Portuguese Government in complying with the measures for the health sector that were laid out in the MoU (first version, May 2011; revised September 2011).

All comments, suggestions and corrections welcome. Even questions are welcome (though I may not have the answer).


Required by the Memorandum of Understanding, update of September 2011

Current status of progress and implementation, October 2011


Assess the 20 most relevant public-private partnerships.

A report was produced, covering almost all PPPs, including the
health sector. It is publicly available.


Revision of exemptions from user charges. Means-testing to be
done in cooperation with Ministry of Social Security. (3.51)

Approved by Government at 29.09.2010. Exemptions are to be based
on two criteria: lack of financial means, clinical need (chronic conditions).


Increase of user charges, ensuring that values are higher in
hospitals than in primary care; higher in emergency
room than in outpatient visits. (3.51)

Approved by Government at 29.09.2011. Values will be published
in a specific legal document. Not yet available.


Set the maximum price of the first generic at 50% of the
originator price. (original May 2011: Set the
maximum price of the first generic at 60% of the originator price.)

Approved by Government at 29.09.2011.


"Improve the monitoring system of prescription of medicines
and diagnostic; set in place a systematic assessment by individual doctor in
terms of volume and value" (3.59)

28.09.2011 – Despacho n 12950/2011
(Government Directive). Sets the minimum information to be reported. A
preliminary report was produced on 19.09.2011. According to press, individual
reports were sent to doctors.


Mandatory electronic prescription of pharmaceutical products and
exams paid by the NHS (3.58)

It is in place since 01.08.2011.  Few exceptions exist.


"Induce physicians at all levels of the system, both public
and private, to prescribe
generic medicines and the less costly available branded product" (3.60)

Not clear how to be done. Public statements reinforce this
intention. Portuguese Medical Association revealed that most physicians
prescribed generics (26.09.2011)


Set legal framework for centralized purchasing and procurement.

SPMS is a public entity taking this role. It existed prior to
the MoU. It publicizes procurement tender offers in
the web (


Stronger role to primary care, to reduce the use of hospital
emergency services. In particular, more "family health units" (USF)
should be created. (3.72)

There were 18 new USF since May, in a total of 311. This likely
reflects previous applications. Since May 2011, 19 new applications.


Recover arrears. Set procedures to avoid them in the future.

No public information is available. News in the press reports
increasing arrears. The Government budget proposal for 2012 recognizes arrears
in the amount of 3,000 M€ (total NHS budget for 2012 around 7,500 M€). A plan
for recovery of arrears was announced to be disclosed
until the end of 2011.


Detailed measures to achieve cost savings in hospitals. Target
value 200M€ over two years (2011 and 2012) (3.75)

The Government budget proposal for 2012 entails a 14% reduction
in wage payments to all civil servants. Reduction of over-time work payments,
both in value per hour and volume of hours. Own estimate of overall cost
savings: 300 – 400M€ yearly.


Publication of clinical guidelines. Set audit system for
monitoring. (3.76)

A5 05.09.2011, a protocol between the Ministry of Health and the
Portuguese Medical Association to build clinical guidelines and train auditors
was signed.


Monitor annually the demographic dynamics of physicians by
specialty, age, region, hospital, sector, to identify future needs. ((3.82)
The review added other professions, and the regions of Madeira and the

A study was produced by the ACSS, the financial agency of the


Prepare annual reports on the allocation of human resources.

No separate report. Can be seen as part of the report on medical
doctors’ needs, prepared by ACSS.


Reduce the costs with
patients’ transportation by 1/3. (3.87)

A new regulation on
transport of non-urgent patients was enacted in May 2011. According to press,
transport of patients decreased 30% in the first semester. No information
about costs.


Reduce fiscal credits to
health expenditures by 2/3.

Budget proposal for 2012
reduces fiscal credits to 2/3. In the two upper income brackets, no fiscal
credits are allowed.


Set mechanisms to ensure a
more balanced distribution of GPs across the country. (3.72)



All PPP (including health
sector PPP) are to be reviewed by an international auditor company.

 Seems to be under
way. No precise information was found.


User charges are to be
automatically indexed to inflation. (3.51)

Approved by Government at


Reduction in budget costs
associated with ADSE, ADM, and SAD (civil servants and military health
services). 30% in 2012. (3.53)

The Government budget
proposal for 2012 satisfies this for the military. As to ADSE (civil
servants), accounting changes do not allow a clear reading. A significant
reduction seems to be in place.


 Automatic reduction
of original pharmaceutical product prices when patent expires. (3.55)

Approved by Government at


"Move the
responsibility of pricing medicines to the Ministry of Health (for example to
the Infarmed)."

Approved by Government at


Revise the international
referencing system, using three countries of comparable GDP and with the
lowest prices within Europe. (3.57)

Approved by Government at
29.09.2011. Details yet to be known.


"Improve the
monitoring system of prescription of medicines and diagnostic and set in
place a systematic assessment by individual doctor in terms of volume and
value, vis-à-vis prescription
guidelines and peers" (3.59)

Despacho n 12950/2011
enacted by the Ministry of Health details information to be collected.
Monitoring template not publicly known.


"Establish clear
rules for the prescription of drugs and the realization of complementary
diagnostic exams (prescription guidelines for physicians) on the basis of
prescription guidelines" (3.61)

At 05.09.2011, a protocol
between the Ministry of Health and the Portuguese Medical Association to
build clinical guidelines and train auditors was signed.


Remover barriers to entry
of generics, in particular administrative and legal hurdles. (3.62)

New legislation to remove
barriers is under discussion in Parliament.


implement the existing legislation regulating pharmacies" (3.63)



Change margins of
pharmacies from constant percentage mark-up to regressive margins and fixed
fees. (3.64)

Under discussion to be
included in a new piece of legislation.


"Finalize the uniform
coding system and a common registry for medical supplies." (3.67)

Under way by Infarmed
(pharmaceutical sector regulator) and SPMS (centralized procurement agency
for the health sector).


 ((3.74) "change the existing accounting framework and adopt
accounting standards" to improve hospital management.)



Increase competition
among private providers to the NHS. Reduce expenditure by 10% in 2011 and
another 10% in 2012. (3.68)

On 04.10.2011, the
Minister of Health announced a reduction in this expenditure in a conference.
Price reductions in laboratory tests and radiology were established. Dialysis
prices were reduced. Expected price reductions are of 12.5%. Hospitals are to
use internal idle capacity before outsourcing exams and tests to the private


a more transparent selection of the chairs and members of hospital
boards" (3.77)

No public information.
Currently the Ministry of Finance publishes who is in the board and the
remuneration of hospital boards with firm-like statutes.


Publish a strategic plan
for the health sector, consistent with medium-run budget framework. (3.54)


Autor: Pedro Pita Barros, professor na Nova SBE

Professor de Economia da Universidade Nova de Lisboa.

One thought on “Assessment of implementation of Troika measures in the health sector

  1. Portugal bom aluno (marrão). A cabeça baixa não lhe permite ver a transformação alucinante da realidade a que assistimos todos os dias. Destino anunciado: Desemprego com nota dez obtida no exame final.


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