An Incentive-Based Framework for Analyzing the Alignment of Institutional Interventions in the Public Primary Healthcare Sector: The Portuguese Case

Over the years, the Portuguese National Health Service has undergone several reforms to face the challenges posed by internal and external factors on the access to and quality of its health services. One of its most recent reforms addressed the primary healthcare sector, where understanding the incentives behind the actors of the inherent institutional interventions and how they are aligned with the governing health policies is paramount for reformative success. With the purpose of acknowledging the alignment of the primary healthcare sector’s institutional interventions from an incentive-based perspective, we propose a framework resting on a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis, which was built in cooperation with a panel of decision-making actors from the Portuguese Ministry of Health. In the end, we derive possible policy implications and strategies. This holistic approach highlighted the positive impact of the primary healthcare reform in the upgrade of physical resources and human capital but stressed the geosocial asymmetries and the lack of intra- and inter-sectorial coordination. The proposed framework serves also as a guideline for future primary healthcare reforms, both national- and internationally.info:eu-repo/semantics/publishedVersio

A step forward on order-α robust nonparametric method: inclusion of weight restrictions, convexity and non-variable returns to scale

Partial frontiers have been recently developed in order to overcome several drawbacks of the traditional nonparametric techniques. These robust frontier (order-a and order-m) methods avoid the curse of dimensionality, are less sensitive to outliers and extreme data and may include direct environmental information in the model. Nonetheless, the disadvantages of these partial frontier-based methods according to the formulation proposed in the literature are that they do not allow weight restrictions or non-variable returns to scale technology. The procedure here proposed is an extension of the traditional order-a method, allowing the estimation of an empirical convex a-level, assuming also some additional constraints, such as the virtual weight restrictions and non-variable returns to scale. In the particular case of nonconvex attainable sets, unrestricted formulations and variable returns to scale assumption, the proposed procedure returns the same results as the standard order-ainfo:eu-repo/semantics/publishedVersio

A Critical Analysis of Decentralizing the Portuguese Public Healthcare Provision Services

The Portuguese health system has a universal, public, general National Health Service (NHS), tending towards free healthcare access. Created in 1979, this delivery model developed from the integration and complementarity between the different response levels (primary, hospital, continuing, and palliative care). However, over the last 40 years, the initially centralized system underwent a decentralization process with the creation of Regional Health Administrations in the five mainland administrative regions. Since then, the entire NHS has settled around this new organization. The most recent step started in 2018 with the decentralization of primary healthcare skills to 190 municipalities. This paper presents the various critical issues involved in the latest gradual decentralization process in health, intending to bring services closer to the citizens, and to be more focused on their needs. The article identifies and discusses the implications of this experience based on the steps foreseen in the already-published legal texts.info:eu-repo/semantics/publishedVersio

Operational efficiency vs clinical safety, care appropriateness, timeliness, and access to health care

Health care systems face resource scarcity that may jeopardise their financial sustainability as well as the quality of delivered health care. In view of that, the association between technical efficiency, access, and quality of services should be investigated, despite some past attempts that led to mixed, unclear, and perhaps biased results. We use a dataset composed of financial resources, hospital services, appropriateness and timeliness of care, patients’ clinical safety, access to health care services, demographics, and epidemiology variables to study the aforementioned link regarding the Portuguese public hospitals (operating between 2013 and 2016). Quality and access data are aggregated into three main composite indicators, through Grey Relational Analysis (GRA). Bias- and environmentally corrected efficiency scores are estimated via bootstrap-based directional Data Envelopment Analysis. A double bootstrap algorithm is employed, using GRA-based quality indicators as predictors of technical efficiency. Evidence suggests that (1) Portuguese public hospitals exhibit low performance in terms of quality, while the different indicators present considerable correlation among them and with hospital size and patients’ complexity characteristics; (2) patients’ clinical safety, appropriateness and timeliness, as well as access to health care services are consistent and significant predictors of technical efficiency; and (3) the association between efficiency, quality, and access depends on the interaction between appropriateness, timeliness, and access. Therefore, quality and access can be improved with no efficiency sacrifice and vice versa.info:eu-repo/semantics/publishedVersio

Investment in drinking water and sanitation infrastructure and its impact on waterborne diseases dissemination: The Brazilian case

Investment in sanitation and drinking water infrastructure is essential for universal access to these services in developing countries. Universal coverage of water and sanitation services (WSS) can prevent the dissemination of waterborne diseases and mitigate their adverse effects. These diseases are responsible for many deaths worldwide, especially among the disadvantaged population and children. A causal effect can be established between WSS investment and hospital admissions due to waterborne diseases. Therefore, we considered an innovative network-DEA approach that models the link between serially connected subsystems (upstream investment and downstream hospitalizations). This approach allowed us: to measure the efficiency of both subsystems; estimate the amount of (efficient) investment necessary to universalize the access to proper WSS infrastructure; and mitigate hospital admissions due to waterborne diseases. We used the Brazil case study to test our model. On average, Brazilian states could increase the number of people not requiring hospitalizations due to waterborne diseases by 157 thousand per R$100 million invested in sanitation and 26 thousand per R$100 million invested in drinking water. Our results suggest that relatively small (efficient) investment in those two infrastructure types has a massive impact on hospitalizations. This impact would be more significant than the investment in WSS coverage. Therefore, if safely managed, WSS would cover all citizens, and Brazil would come closer to developed countries.info:eu-repo/semantics/publishedVersio

Pay for performance in health care: a new best practice tariff-based tool using a log-linear piecewise frontier function and a dual–primal approach for unique solutions

Health care systems worldwide have faced a problem of resources scarcity that, in turn, should be allocated to the health care providers according to the corresponding population needs. Such an allocation should be as much as effective and efficient as possible to guarantee the sustainability of those systems. One alternative to reach that goal is through (prospective) payments due to the providers for their clinical procedures. The way that such payments are computed is frequently unknown and arguably far from being optimal. For instance, in Portugal, public hospitals are clustered based on criteria related to size, consumed resources, and volume of medical acts, and payments associated with the inpatient services are equal to the smallest unitary cost within each cluster. First, there is no reason to impose a single benchmark for each inefficient hospital. Second, this approach disregards dimen sions like quality (and access) and the environment, which are paramount for fair comparisons and benchmarking exercises. This paper proposes an innovative tool to achieve best-practices tariff. This tool merges both quality and financial sustain ability concepts, attributing a hospital-specific tariff that can be different from hospital to hospital. That payment results from the combination of costs related to a set of potential benchmarks, keeping quality as high as possible and higher than a user-predefined threshold, and being able to generate considerable cost savings. To obtain those coefficients we propose and detail a log-linear piecewise frontier function as well as a dual–primal approach for unique solutions.info:eu-repo/semantics/publishedVersio

A critical look at the Portuguese public–private partnerships in healthcare

The pre‐conceived idea that contracts in a public–private partnership (PPP) regime, in healthcare or in any other economic sector, are, as a rule, ruinous and appealing for only a share of the stakeholders, lacks a solid basis that confirms it. This idea, outset and nurtured by the media, has been instigating the distrust of the users who, in turn, demand a more rigorous and efficient utilisation of public resources. Being Portugal in the top of countries that resort to PPPs, it is urgent to inquire if its respective contracts originated an inefficient and ineffective management of resources. It is precisely this discussion that we address in this paper, focusing our efforts in the Portuguese healthcare sectorinfo:eu-repo/semantics/publishedVersio

Economic Inefficiency Levels of Urban Solid Waste Management Services in Portugal

Key performance indicators (KPI) are widely used tools to evaluate the economic (in)efficiency of services, including the ones devoted to urban solid waste management. Regulatory exercises are, then, mostly based on the outputs from KPIs, raising some questions about their validity. In theory, other more appropriate tools could be used to estimate those efficiency levels. This study evaluates the economic inefficiency level of urban solid waste management services in Portugal (2010–2017) through the adoption of partial frontier benchmarking models (order-m) coupled with weight restrictions. That way, the constructed model can evaluate the performance of those services under some regulatory and sustainability requirements. Then, estimated efficiency levels and some common KPIs are compared in order to understand if the latter are sufficient to explain the economic efficiency. The novelty of this research lies in two main aspects: (a) the utilization of a robust order-α model coupled with weight restrictions linked to regulatory and sustainability impositions to estimate efficiency, and (b) the comparison of economic efficiency and some commonly used KPIs, including waste fractions and recycling rate. Results point towards efficiency distributions that follow Weibull functions, with the average close to 50%; thus, nearly half of the resources have been well spent in municipal solid waste management services since 2010 onwards. Nonetheless, in an efficient system, that average would be close to 100%. Additionally, the considered management related KPIs do not exhibit any relationship with economic efficiency, which means that their interpretation and usefulness for regulatory issues are both limited and should be used carefully. In other words, those KPIs are not good performance drivers and carry no capacity to explain economic (in)efficiency in urban solid waste management services.info:eu-repo/semantics/publishedVersio

Quality assessment of the Portuguese public hospitals: A multiple criteria approach

The Portuguese National Health Service (SNS) was created to provide universal, equal, and tendentiously free care. There are different levels of care (primary, secondary, continued, and palliative) and all of them should deliver quality care services. Quality in healthcare is assessed according to several criteria, such as patient safety, care appropriateness or access. However, over the last years political and economic events have had an impact on the SNS. Hence, structural reforms have occurred, and new healthcare policies have been implemented, mostly focused on improving efficiency and reducing costs. It associated to di vestment can increment barriers to access, compromise infrastructures and equipment, and, above all, the service’s quality. This work aims to assess quality of the Portuguese public hospitals (secondary care providers) in this line. To this aim, we adopt a multiple criteria decision aiding approach, applying the Electre Tri-nC method to build a decision model with intervention of an expert, who acts as the decision maker. Hospitals are assessed and assigned to predefined categories, taking into account the hospitals’ performances on various criteria. Each criterion is characterized by different subcriteria, resulting in a complex criteria tree. Thus, to construct a multidimensional scale for each criterion, we propose an innovative approach using an Electre Tri-based method. The results are analyzed and the robustness of the model is tested. This work’s findings may have potential application to healthcare policy and hospital funding in the SNS, in which financial sustainability is a permanent challenge.info:eu-repo/semantics/publishedVersio