The quality of health governance in Portugal: an evaluation of the Troika’s intervention period

Pinto, Ricardo Ramos; Monteiro, Maria Helena; Martins, Manuel Meirinho; Carvalho, Elisabete Reis de

doi:10.1590/1413-81232021266.10672019

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FREE THEMES • Ciênc. saúde coletiva 26 (6) • June 2021 • https://doi.org/10.1590/1413-81232021266.10672019 copy

The quality of health governance in Portugal: an evaluation of the Troika’s intervention period

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This study aims to evaluate the quality of the Portuguese Government’s action in the health sector during Troika’s intervention period (2011-2015), taking as criterion the concern with the application of Good Governance principles, in terms of degree and diversity. The intention is to understand the extent to which the public action promoted by the Ministry of Health has developed seeking to contribute to the strengthening of Good Governance practices. Fifty measures of the Ministry of Health, distributed by nine intervention areas, were analyzed, based on documental analysis, supported on the law and on other official documents. The principles of Good Governance that demonstrate a more transversal concern are clearly that of “transparency” and of “effectiveness/efficiency”, present in eight of the nine intervention areas. The concern with “orientation to consensus” is essentially present in the measures classified as Agreements, “independence” in the Ethics area, the “strengthening of the rule of Law” in the Control area and “equity/inclusion” in the area of the Citizen in the Centre of the NHS.

Key words
Good governance; Health; Portugal; Troika

Good Governance Principles	Definition	Operationalization Model
Accountability	To create conditions to bind the organizations and its managers to account for their actions and decisions to the remaining stakeholders and overall public. The accountability principle is associated to the principles of transparency and reinforcement of the rule of law	- Strengthening of the data transparency (existence of 24/7 information systems) - Execution of regular meetings with the NHS' Top Managers - Availability to clarify the doubts of supraministry entities and remaining stakeholders - Promotion of the managers' autonomy - Promotion of accreditation and quality
Efficiency and effectiveness	To create conditions to produce outcomes that meet the society needs, better using the available resources that contribute for a cost reduction without sacrificing the outcomes' quality	- Promotion of the cost's reduction - Use of cost-benefit analysis - Analysis and/or promotion of financial sustainability - Investment regulation and control - Boost for the reduction of inefficiencies - Rationalization of spaces - Profitability of the installed equipment - Reinforcement of health care - Reinforcement of the health promotion
Transparency	To create conditions to bind and commit the institutions to provide clear and precise information, which is an added value to the remaining stakeholders. All initiatives which promote the stakeholders' trust on the decision-making and management processes are included	- Strengthening of the data transparency (existence of 24/7 information systems) - Renegotiation of the agreements - Inclusion of investigated cost-benefit analysis in the agreements - Strengthening of the ethical issues - Articulation with the Court of Auditors - Public interventions of the ministry's team - Promotion of external assessments - WHO Universities
Participation of the stakeholders	To create conditions to, in an organized way, involve and commit the parties interested on the outcomes and their effectiveness. The participation on the decision-making processes may be carried out direct or indirectly, through institutions with legitimate representativity	- Negotiations and Agreements with relevant stakeholders of civil society (Professional Associations or Entities) - Articulation, in negotiations, with the Ministry of Finance and Social Security - Creation of conditions for the participation in negotiations of the Ministry of Health's institutions of direct or indirect management
Reinforcement of the rule of law	To contribute for the existence of a fair legal framework, effectively and impartially applied, which is a support to the equity and justice claims	- Execution of internal audits - Execution of external audits - Reinforcement of the inspections - Interventions of the Court of Auditors, Criminal Policy and Public Prosecution - Reinforcement of the intervention of the Health Regulatory Authority (HRE) - Creation of legislation on conflicts of interest - Promotion of the fight against fraud
Responsiveness	To create conditions so that the Ministry of Health and other dependent entities may offer to the stakeholders an appropriate answer, within a reasonable period	- Reinforcement of the health care network - Innovation on the negotiation with the pharmaceutical industry - Creation of reference centers - Promotion of quality - Reinforcement of the NHS' human resources and skills - Reinforcement of the NHS' information systems and technologies - Promotion of health - Promotion of disease prevention
Orientation towards consensus	Mediation of the different interests within the health sector, promoting a broad consensus on the objectives to be established and how to achieve them	- Participation, in negotiations, of the Ministry of Finance and Social Security - Participation, in negotiations, of the Ministry of Health's institutions of direct or indirect management - Participation, in negotiations, of the public, social and academic sector and civil society
Equity and inclusion	To create conditions to ensure the access, to all citizens, to health care, acknowledging that their needs and capacities are different	- Improvement of the access to health care - Promotion of the service's quality - Creation/improvement of the communication mechanisms with the patient - More favourable access to medicines - Reinforcement of free vaccination - Promotion of a greater connection of the Hospitals' Advisory Boards to the region they serve
Independency	To create conditions for the decisions to be made without influence, pressure or duress, external or internal	- Purchase processes by shared services - Strengthening of the ethical issues - Promotion of the management's autonomy - Creation of legislation on conflicts of interest and incompatibility schemes Purchasing processes for shared services

AI	Orientation of the initiatives - main objectives	A	C
Agreements	Initiatives that promoted the negotiation and establishment of agreements with multiple players outside the Ministry of Health, but with an impact on NHS performance. These agreements resulted in new negotiation methodologies, new contractual models, follow-up and monitoring commissions with the inclusion of all parties, and also the setting up of processes that allow the assessment of the effectiveness of the agreements based on transparent information for the players	7	95%
Citizen in the center of the NHS	In addition to ongoing health promotion actions, it includes initiatives aimed at promoting greater access to health care for the elderly and vulnerable. It also includes: the reformulation of palliative and continuing care networks; the appointments of the presidents of the hospital advisory boards (41 appointments from 2012 to 2015) whose mission is to include the citizen in the strategy and administration of the hospital or local health unit	9	30%
Communication and action with the stakeholders	Initiatives dedicated to establishing flows of information and accountability to stakeholders on the projects, actions and results of the Ministry of Health's performance. This area was strongly driven by ACSS for providing data for hospital benchmarking and ACES. Another initiative is the multiplicity of times that the Minister and officials of the Ministry went to the Assembly of the Republic to answer to the parliamentary committees and the plenary	3	90%
Efficiency	There were also four-monthly progress meetings between the Minister of Health and the Ministry's managers	8	50%
Control	Initiatives aimed at improving the management of all the Ministry's institutions by strengthening the continued mechanisms for verifying good management, identifying good and bad practices and preparing proposals for recommendations. These inspections and audits are the responsibility of all entities of the Ministry through the internal auditors, the inspection structures (General Inspection of Health Activities) and the regulatory structure (Health Regulatory Entity), as well as entities outside the Ministry (Court of Auditors)	9	95%
Ethics	Initiatives aimed at strengthening ethics issues in all Ministry institutions, allowing for more confidence-based interactions regulated by a set of rules negotiated and agreed upon by participants in the internal network (including rules ensuring protection of conflicts of interest between Ministry staff) and external to NHS. This includes the Committees of the National Ethics Council for Life Sciences (CNECV) and the Ethics Committee for Clinical Research (CEIC)	4	95%
Anti-Fraud	Initiatives aimed at fighting fraud and waste. To this end, the Ministry emphasized not only the detection of anomalous situations through the Invoice Conference Centre but also the articulation with the Criminal Police and the Public Prosecution. During this period, the Ministry reinforced twice the number of inspectors of the General Inspection of Health Activities	3	95%
Innovation in the Processes	Initiatives aimed at innovation and administrative modernization, particularly in the Purchasing sector and in the development of information systems and technologies. Through horizontal and interoperable platforms, involving all hospital and primary care institutions, the central entities of health administration and the citizen, enhancing interaction with the NHS through digital means. For example, we mention the electronic health record, the health data platform, the medical electronic prescription and the dematerialization of prescriptions	3	50%
Quality	Initiatives aimed at ensuring higher quality for NHS patients, such as combating nosocomial infections, creating standards of clinical guidance and mechanisms for their monitoring, reducing caesarean rates, and also initiatives aimed at providing more health care safety, such as the personal card for rare diseases, combating antibiotics, the national incident reporting system, among others. In this area, we included the accreditation of quality systems in hospitals and ACES initiated, ongoing and completed in this period, as well as the strengthening of human resources and their empowerment in healthcare activity	4	50%

#	Area	Initiative	Number of Sub-Initiatives	Accountability	Efficiency and Effectiveness	Transparency	Participation of Stakeholders	Reinforcement of the Rule of Law	Responsiveness	Orientation towards consensus	Equity and inclusion	Independency	Total
11	Agreements	Revision of the Conventions (amendment of the legal)	1			2	3			1			3
12	Agreements	Agreements with the Pharmaceutical Industry	1		2		3			1			3
13	Agreements	Agreements with the National Pharmaceutical Association	1		2		3			1			3
14	Agreements	Agreements with Medical Unions	1			2	3			1			3
15	Agreements	Agreements with Misericórdias / New forms of articulating with the third sector	1		2		3			1			3
40	Agreements	Agreement with the Portuguese Firefighters League	1		2		3			1			3
41	Agreements	Agreement with the Nurses Union	1			2	3			1			3
Subtotal			7	0	4	3	7	0	0	7	0	0	21
7	Communication and action with the Stakeholders	Data Transparency	8	1	3	2							3
23	Communication and action with the Stakeholders	Minister's Situations Meetings with NHS Management	1	1	3	2							3
35	Communication and action with the Stakeholders	Intervention by the members of the Government in the area of Health in the Assembleia da República (Parliament)	3	1		2		3					3
Subtotal			12	3	2	3	0	1	0	0	0	0	9
8	Efficiency	Mandatory cost information note	1	3	1	2							3
9	Efficiency	Reduction of excessive margins / opacity prices	1		1	2	3						3
10	Efficiency	Agreements with cost analysis / scrutinable benefits	1		1	2	3						3
16	Efficiency	Inclusion of EPE Hospitals in the Central Government Budget Perimeter	1	2	1	3							3
42	Efficiency	Increase of the Autonomy of the EPE Board of Directors	1	2	1							3	3
44	Efficiency	Inclusion of ADSE in the Ministry of Health	1		1				2		3		3
45	Efficiency	Space Occupation Rationalization Program	1		1		3			2			3
46	Efficiency	Heavy Equipment driver certification	1		1		3		2				3
Subtotal			8	3	8	4	4	0	2	1	1	1	24
1	Control	External Audits to all the NHS units	1	2		3		1					3
2	Control	Appointment of the Heads of Internal Audit Officers	1	2		3		1					3
5	Control	Reinforcement of the competencies of the General Inspectorate of Health Activities	1	2		3		1					3
6	Control	Reinforcing licensing and evaluation competencies of the Health Regulator	1	2		3		1					3
43	Control	Monitorization of the MoU measures	1		2	3		1					3
28	Control	Statements by the Court of Auditors	1	2		3		1					3
33	Control	Changes in the Legislation of the Orders	1	2		3		1					3
47	Control	Request by the Ministry of Health for a Legal Auditor	1	2		3		1					3
48	Control	External Evaluation	7	2		3		1					3
Subtotal			15	8	1	9	0	9	0	0	0	0	27
3	Ethics	Reformulations of the Conflicts of Interest and Incompatibility Rules	1			2		1				3	3
17	Ethics	NHS Code of Ethics	1			2		1				3	3
36	Ethics	CNECV and CEIC intervention	1			2		1				3	3
49	Ethics	Commission for Medically Assisted Breeding	1			2		1				3	3
Subtotal			4	0	0	4	0	4	0	0	0	4	12
4	Citizens in the centre of the NHS	Dinamização dos Conselhos Consultivos	1		3				2		1		3
20	Citizens in the centre of the NHS	Gilead - Hepatite C - 2015	1		3				2		1		3
21	Citizens in the centre of the NHS	More affordable health for the most vulnerable	1		3				2		1		3
22	Citizens in the centre of the NHS	Improved access to medicine	1		3				2		1		3
24	Citizens in the centre of the NHS	Paliative Care Network	1		3				2		1		3
25	Citizens in the centre of the NHS	Reinforcement Continuing Care Network	1		3				2		1		3
26	Citizens in the centre of the NHS	Free Flu Vaccination > 65 years and Prevenar13	1		3				2		1		3
27	Citizens in the centre of the NHS	Health Line 24 Senior	1		3				2		1		3
38	Citizens in the centre of the NHS	Health Promotion / Disease Prevention (tobacco, alcoholism, drugs / smartphones	1		3				2		1		3
Subtotal			9	0	9	0	0	0	9	0	9	0	27
18	Anti-Fraud	Anti-Fraud Infrastructures	3		2		3	1					3
31	Anti-Fraud	Interventions by the Research Police	1		2	3		1					3
32	Anti-Fraud	Public Prosecution Interventions	1		2	3		1					3
Subtotal			5	0	3	2	1	3	0	0	0	0	9
30	Innovation in the process	SGMS Public Purchasing Process	1		1	3						2	3
29	Innovation in the process	SPMS Public Purchasing Process	1		1	3						2	3
37	Innovation in the process	Information Systems and Technologies in the NHS	15		1	3			2				3
Subtotal			17	0	3	3	0	0	1	0	0	2	9
34	Quality	Accreditation - Quality Systems	1	2	3				1				3
39	Quality	Reinforcement of the Human Resources and Leadership Skills	1		2	3			1				3
50	Quality	Health Quality	6				3		1		2		3
19	Quality	Reference Centres	1		3				1		2		3
Subtotal			9	1	3	1	1	0	4	0	2	0	12
Total			86	15	33	29	13	17	16	8	12	7	150
Global weight of each principle			-	10%	22%	19%	9%	11%	11%	5%	8%	5%	-

Good Governance Principle	Area(s) of intervention where the principles has maximum incidence
Efficiency and Effectiveness	Efficiency Citizen in the center of NHS Anti-Fraud Innovation in the processes
Transparency	Control Ethics Innovation in the processes
Reinforcement of the Rule of Law	Control Ethics Anti-Fraud
Responsiveness	Citizen in the center of NHS Quality
Accountability	Communication and action with the stakeholders Control
Equity and Inclusion	Citizen in the center of NHS
Participation of the stakeholders	Agreements
Orientation toward consensus	Agreements
Independency	Ethics

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