A Organização Mundial de Saúde – Europa elaborou um estudo designado por “Portugal Health System Performance Assessment”, que visou avaliar o desempenho do sistema de saúde português. O seu principal objectivo foi analisar e medir os resultados do Sistema e fornecer, aos decisores políticos, recomendações que contribuam para a melhoria global do desempenho.
Os resultados baseiam-se na análise estatística de um conjunto de indicadores de desempenho, em entrevistas e nos contributos resultantes de uma mesa redonda com decisores políticos, intervenientes no sistema de saúde (a nível nacional, regional e local) e peritos.
O estudo, agora disponível em livro, foi realizado no âmbito de um protocolo de colaboração assinado, em 2008, entre o Ministério da Saúde de Portugal e a Organização Mundial de Saúde – Europa.
“There have been significant improvements in measures of population health status and in health care outcomes
• Life expectancy at birth has improved dramatically over the past 25 years; the gap in life expectancy compared to the average for the European Union (EU 15 group of countries)1
decreased from 3 years in 1980 to 1½ years in 2007. Potential years of life lost (premature death) were 40% more than the EU 15 median in 1980 but only 20% more in 2003.
• Perinatal and infant mortality rates (deaths in the first 7 days and in the first year of life, respectively) were the highest of the EU 15 countries in 1980 but were better than the EU 15 average in 2007.
• Mortality rates for some key causes of death under the age of 65 years have decreased since 2000; in particular, mortality due to circulatory diseases such as ischaemic heart disease and cerebrovascular accidents has fallen substantially, as has the rate of death due to motor vehicle accidents. Thirty-day fatality rates following a stroke or heart attack have dropped by roughly a quarter since 2000. The 5-year survival rates for cancers detected at early stages have improved over the past 10 years.
Nevertheless, some results are troubling and significant challenges remain
• A number of morbidity indicators, such as selfassessed health status and disability-free life expectancy, have not shown similar improvement and results continue to be low in relation to other EU 15 countries.
• There are still sizeable inequalities2 in health status between men and women and among geographical regions. Women live longer than men, but women appear to live in a poorer state of health with a shorter disability-free life expectancy and lower self-assessed health status than men. Life expectancy is shorter in the less populated and less urban regions of Portugal.
• Rates of obesity have been increasing for both men and women and across all age groups. There hás been no improvement in the overall smoking rate in Portugal – a decrease in the rate among men hás been offset by a very troubling increase in the rate among women.
• The Portuguese appear less satisfied with the availability and quality of health care than citizens of other EU 15 countries.
• Mortality amenable to health care and health promotion interventions improved between 1997–1998 and 2002–2003, but not as much as in other EU 15 countries, and Portugal had the highest rate of amenable mortality among the EU 15 countries in 2002–2003.
• Total expenditure on health has increased substantially over the past decade. However, the increase in private expenditure, including out-of-pocket payments and cost sharing, has been disproportionate, placing an additional burden on disadvantaged households and potentially limiting access to care.
• There are critical gaps in health information in Portugal that may limit the potential to develop health system policies and strategy on the basis of sound evidence. There were limited data on measures of safety and health and it is difficult to assess and monitor the extent of socioeconomic inequalities in health. The gaps in health information also limit the capacity to support transparency and accountability through public reporting of results.
There are opportunities to respond to these challenges and improve health system performance. However, two significant threats to the system may limit capacity to achieve results: (a) current patterns of risky health behaviour, in particular rates of smoking and the prevalence of obesity, will constrain improvement in health status; and (b), any responses to the challenges must be fiscally sustainable. Within this context, the following core policy recommendations can be formulated.
1. Promote health policies targeting health gains and reduced health inequalities in all sectors. Ensure that decisions and investments are planned and undertaken together with other ministries and agencies to exert influence on overall government effectiveness.
2. Invest in upstream and gender-responsive health promotion activities in order to tackle risk factors and integrate the determinants of health into public health, health promotion and disease prevention programmes.
3. Ensure a broader engagement of patients and the general public in health system decision-making and take the leadership for broader public engagement across government activities.
4. Increase value from investments in health by prioritizing spending on primary health care and public health, and by enhancing the efficiency of service delivery.
5. Clarify the role of the private sector through a coherent policy framework: regulate and ensure compliance with requirements for public reporting, standards of quality and safety, rules for dual employment, and pricing and payment mechanisms.
6. Improve the coherence of public coverage and subsystem coverage by progressively shifting the role of subsystems to supplementary coverage.
7. Develop more coherent approaches to the decentralization of health service delivery: further decentralize decision-making authority, including budgetary and financial autonomy, together with corresponding accountability and performance management.
8. Reduce barriers to the affordability of health care services: the relatively high level of out-of-pocket spending on health care services in Portugal requires policies to reduce their impact, particularly on disadvantaged households.
9. Develop strategies on human resources for health that include planning for both appropriate numbers and mix, addressing professional scope of practice, and clarifying the role of professional councils.
10. Ensure that health information capacity is sufficient to promote the use of evidence in developing policy and in responding to requirements for transparency and accountability. A critical element in improving health system performance with limited resources is the ability to make policy choices to allocate resources in áreas where they can be most effective in improving health and equity in health. It is essential to develop the policy decision-making capacity to address reallocation of resources based on evidence, recognizing that, although “health” is the ultimate goal of the health system, other social systems and policies have a significant impact on the level of health and on health inequalities.
(1)Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain, Sweden and the United Kingdom.
(2) Health inequalities refers here to avoidable and unjust systematic differences in health status between different groups in a given society (inequities) and not all inequalities. Where the terms inequity or inequities are used in this publication it is because the particular reference or study used this term. For example, the final report of the Commission on Social Determinants of Health specifically refers to health inequities.”
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