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Chapter 9 | The impact of the crisis on the health system and health in Portugal 295 allocation to the NHS decreased by 13.5% between 2010 and 2012, but if the additional expenses are included, the NHS budget decreased by 14.4%. Using this calculation of the NHS budget, the budget allocation to finance the NHS in 2012 and 2013 was, in nominal terms, below the 2006 level and even below the final allocation of 2005. As a share of GDP, the NHS budget decreased each year from 2009 until 2012. Changing rules for financing public insurance of public servants The Directorate-General of Social Protection for Workers in Public Administration (Direção-Geral de Protecção Social aos Funcionários e Agentes da Administração Pública; ADSE) is a public fund for public servants and their families. Its beneficiaries have dual public health service coverage through the NHS and ADSE. ADSE provides complementary health care coverage for about 13% of the population and is an important source of revenue for the private sector. As a result, historically it has been politically difficult to reform ADSE. ADSE is one of three existing subsystems, the others being Assistência na Doença a Militares, which provides care to the armed forces, and Assistência na Doença da Polícia de Segurança Pública, which provides care to police. The AP stated that the cost of existing subsystems should be reduced by 30% in 2012 and a further 20% in 2013. Further reductions were planned in subsequent years with the goal that these subsystems will be self-sustainable by 2016. The costs of these schemes will be reduced by lowering the employer contribution rate to 1.25% in 2013, increasing employee contributions and adjusting the scope of health benefits. Phasing out of fiscal credits for private health care expenditure In 2012, tax credits for private health care were reduced from a maximum of 30% to 10% of total personal private expenditure. These tax credits have now been discontinued for those in the upper income brackets. 3.2 Changes to coverage Population entitlement There are few explicit changes to coverage for NHS users. Within the health subsystems framework, membership of ADSE has been voluntary since 2011. The benefits package In accordance with the AP, patient transportation costs were to be reduced by one-third by the fourth quarter of 2012 compared with costs in 2010; this was to be accomplished by limiting non-urgent patient transport (e.g. transportation to therapeutic services/rehabilitation) and specific rules were issued to health
296 Economic crisis, health systems and health in Europe: country experience services providers concerning transportation authorizations. In addition, entitlements for patient transportation in non-emergencies is now means tested. Consequently, the target was achieved and transportation costs decreased by 39% (€58 million) between 2010 and 2012 (Ministry of Health, 2013a). User charges The primary change that affects access to services is to user charges. User charges were introduced for the first time in the NHS in ambulatory care in 1980 as “moderating fees”, with the explicit objective of regulating overutilization of health care services. Moderating fees had been fairly stable up until 2011; in 2012 they were increased following implementation of the AP (Fig. 9.6). Fig. 9.6 Evolution of selected user charges in Portugal, 2003–2013 User charges (€) 9 8 7 6 5 4 3 2 1 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 User charges (€) 25 20 15 10 5 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Note: PHC: public health centre. Source: ACSS, 2012b. Hospital (specialist consultations) PHC consultations Hospital basic emergency PHC emergency In the AP, changes to moderating fees were categorized as “financing” and were expected to generate additional revenues of €150 million in 2012 and an additional €50 million in 2013. Changes to user charges in the context of implementing the AP have occurred within three distinct dimensions: increases in user charges, extension of user charges to cover most services, and changes to user charges exemptions. Some of the main increases in user charges that have been implemented since 2011 are summarized in Table 9.5.
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296 Economic <strong>crisis</strong>, <strong>health</strong> <strong>systems</strong> <strong>and</strong> <strong>health</strong> in Europe: country experience<br />
services providers concerning transportation authorizations. In addition,<br />
entitlements for patient transportation in non-emergencies is now means<br />
tested. Consequently, the target was achieved <strong>and</strong> transportation costs decreased<br />
by 39% (€58 million) between 2010 <strong>and</strong> 2012 (Ministry of Health, 2013a).<br />
User charges<br />
The primary change that affects access to services is to user charges. User charges<br />
were introduced for the first time in the NHS in ambulatory care in 1980 as<br />
“moderating fees”, with the explicit objective of regulating overutilization of<br />
<strong>health</strong> care services. Moderating fees had been fairly stable up until 2011; in<br />
2012 they were increased following implementation of the AP (Fig. 9.6).<br />
Fig. 9.6 Evolution of selected user charges in Portugal, 2003–2013<br />
User charges (€)<br />
9<br />
8<br />
7<br />
6<br />
5<br />
4<br />
3<br />
2<br />
1<br />
0<br />
2003<br />
2004<br />
2005<br />
2006<br />
2007<br />
2008<br />
2009<br />
2010<br />
2011<br />
2012<br />
2013<br />
User charges (€)<br />
25<br />
20<br />
15<br />
10<br />
5<br />
0<br />
2003<br />
2004<br />
2005<br />
2006<br />
2007<br />
2008<br />
2009<br />
2010<br />
2011<br />
2012<br />
2013<br />
Note: PHC: public <strong>health</strong> centre.<br />
Source: ACSS, 2012b.<br />
Hospital (specialist consultations)<br />
PHC consultations<br />
Hospital basic emergency<br />
PHC emergency<br />
In the AP, changes to moderating fees were categorized as “financing” <strong>and</strong><br />
were expected to generate additional revenues of €150 million in 2012 <strong>and</strong><br />
an additional €50 million in 2013. Changes to user charges in the context of<br />
implementing the AP have occurred within three distinct dimensions: increases<br />
in user charges, extension of user charges to cover most services, <strong>and</strong> changes to<br />
user charges exemptions. Some of the main increases in user charges that have<br />
been implemented since 2011 are summarized in Table 9.5.
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