Increasing value for money in health systems is a common theme among countries
of the EU. It implies improving outcomes, quality of care and responsiveness while containing
costs. Choices and explicit trade-offs between health and other public services
competing for public funds are not easy to make. In practice, in all countries, this results
in short-term budget constraints for the health system. In this context, a key challenge is
to make efficiency gains, i.e. be able to improve the cost–effectiveness of health care production
as a whole. This is an issue of both accountability in the use of public resources
and a condition to ensure sustainable development of health systems. The concept of
sustainability is built on the premise that a sustainable health system is one that balances
the achievement of good health outcomes with the management of costs. Policies
related to ensuring health system sustainability include not only considerations of financial
sustainability, but also planning and managing the resources needed to deliver care,
such as human resources for health, clinical and technological innovation (diagnostic
and treatment technology) and infrastructure, and health information systems. For the
purposes of this report, health system sustainability is defined as the ability of the health
system to: (a) meet current and future obligations and expectations; (b) adjust to new or
changing demands and unexpected pressures; (c) improve and sustain improvement; and
(d) provide increasing value in terms of both economics and health outcomes. Furthermore,
in a context of increasing fiscal pressure on the health system and raising public
expectations, it is also critical to understand the opportunities that exist for delivering
health services more efficiently.
Although health care expenditure as a percentage
of GDP has increased relative to other OECD countries,
this is partly a result of a lower level of GDP growth
in Portugal. Total growth in health expenditure per
capita during 1997–2006 was below the OECD average
but within the middle of the range of the EU 15 countries
(2). Also, the more recent increase in total health
expenditure per capita appears to have been driven
more by increasing private rather than public spending
on health. Public spending as a share of total health
expenditure fell to below 70% in 2007.
The Stability and Growth Programmes, which
began in 2003 and are continuing, have had as their
key objectives controlling the government budget
deficit and fostering economic growth. In these objectives,
the Programmes have targeted (among many
areas) growth of public spending on health care and
have instituted a number of measures to ensure that
health care spending remains on a sustainable track
(51). The Programmes will have a significant impact
on health system financing, focused largely on human
resources for health and medicines.
The sustainability threats to the health system
could be addressed by taking an investment in health
approach, supported by evidence that well-functioning
health systems contribute not only to health but
also to wealth and economic development through,
for example, workforce development, increased efficiency,
alleviating the costs of illness and lowering
the number of those seeking early retirement due to ill health