Methods
This health system performance assessment was
carried out through a mix of quantitative and qualitative
methods. Quantitative methods comprised the
collection, analysis and interpretation of a core set of
health system performance indicators derived from a
conceptual framework for health system performance
assessment (Fig. 1). A national expert panel discussed
both the framework and the core set of indicators in
February 2009. Indicators were collected and calculated
by various national institutions, including the
National Statistical Institute (INE), the Central Administration
Services of the Ministry of Health (ACSS),
the Directorate General for Health of the Ministry of
Health (DGS) and the National Institute for Pharmaceuticals
(INFARMED). (For a full list of sources see Annex
1.) Qualitative methods comprised: a functional review
of the Portuguese health system (carried out through
four expert missions on, respectively, health system
stewardship and decentralization, health system stewardship
and information management, health system
service delivery and health system financing and
resource generation) between October 2008 and May
2009; numerous interviews with policy-makers, service
providers and health system stakeholders, including
interest groups at national, regional and local levels;
policy analysis; and visits to health facilities in the
public and the private sectors. This assessment was
further informed through the findings of the parallel
evaluation of the NHP for 2004–2010 (21). Finally, a
selective review of the literature in English and in Portuguese
was carried out to support this project.
The assessment was driven by a set of core policy
questions grouped into the chapters of this report.
These policy questions focus primarily on performance
in relation to ultimate goals of the health system and
its determinants. The analysis was supported by the
core set of performance indicators and a functional
analysis of the health system carried out through the
four WHO expert missions mentioned above. The list of
performance indicators used for this assessment and
mapped to the framework and policy questions is presented
in Annex 2. Policy recommendations were built
on the basis of the quantitative and qualitative findings
and on the evidence available on effective policy
interventions, as well as on the advice of experts.
Results for the selected performance indicators
are presented and organized in order to answer specific
policy questions associated with each chapter.
Where available, results are analysed over time, across
regions within Portugal, against international comparators
and, if possible, among social groups. Finally,