Social Equity Initiative

The Short Notes series intends to provide analyses on key topics related with the health sector. This Short Note discusses the role of the public and private sectors within the Portuguese health system across two distinct areas: the financing of healthcare expenditure and the provision of healthcare services. 

The financing of healthcare expenditure in Portugal continues to be predominantly supported by taxes (public sector) and direct out-of-pocket payments by households (private sector). Private health insurance, although it has grown over the past two decades, still plays a relatively limited role. 

An analysis of the relationship between the public and private sectors in healthcare provision shows that, despite the increasing use of private providers and their growing importance as a choice for citizens, the National Health Service remains the cornerstone of the health system. 

The public and private sectors operate in a dynamic of both competition and complementarity, shaped by citizens’ choices and the evolving needs of the health system. The future of public–private articulation in healthcare will depend on the ability to design policies that address existing tensions without compromising the principles of universality, equity, and solidarity that underpin the Portuguese National Health Service. 

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The Short Notes series intends to provide analyses on key topics related with the health sector. This Short Note explores how immigrants' origin (born within or outside the European Union) and their reasons for migrating (economic or non-economic) influence their mental health, access to health care, and health risk behaviors in Portugal. 

Data show that immigrants from other EU countries tend to have better mental health than natives – a phenomenon known as the healthy immigrant effect. This effect is also observed among immigrants who move to Portugal for non-economic reasons. The analysis further reveals that certain groups of immigrants (those born outside the EU; those who migrate to Portugal for economic reasons) face greater financial vulnerability regarding health care expenses, as they are less covered by health subsystems or private health insurance. Additionally, immigrants visit General and Family Medicine consultations less frequently than natives. 

Although no significant differences are found in the use of mental health care services between immigrants and natives, a high percentage of individuals with clinically significant depressive symptoms—both natives and immigrants—do not recognize the need for care. The findings highlight the importance of deepening the understanding of health care access inequalities between immigrants and natives to support the development of public policies that promote equity in the Portuguese health system, particularly within the National Health Service. 

Suggested citation: Barros, P., & Santos, C. (2025). Além-Fronteiras: Saúde Mental e Acesso a Cuidados de Saúde dos Imigrantes em Portugal. Nova School of Business and Economics. https://doi.org/10.34619/k1ig-as2w

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The Short Notes series intends to provide analyses on key topics related with the health sector. This Short Note provides an overview of chronic disease management in European health systems, emphasising the diversity of existing models and their key elements. The review of different approaches to chronic disease management emphasises the absence of a single model. This diversity reflects the complex nature of chronic conditions and the responses required to meet the varied needs of patients and the capacities of health systems. There is a growing focus on the role of patient self-management and the digital transformation of health, which reflect the changing paradigms in healthcare. International experience highlights the importance of the context of each health system in defining the best chronic disease management model. A central element of success is the coherence between the organisational and financial elements used in the chronic disease management model.

Suggested citation: Barros, P. (2024). Sobre a Gestão do Doente Crónico. Nova School of Business and Economics. https://doi.org/10.34619/es7n-fmm3

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The Short Notes series intends to provide analyses on key topics related with the health sector. This Short Note analyses an innovative solution, within the scope of the Portuguese National Health Service, in response to the shortage of family doctors and its impact on access to healthcare. Via Verde Saúde (VVS) is a temporary measure designed to provide primary healthcare services to the most disadvantaged population in the Lisbon area without a family doctor. The creation of VVS was based on a new model of primary healthcare that relies on a multidisciplinary team approach. This Short Note evaluates VVS along three main dimensions: professional satisfaction, patient satisfaction and economic and financial implications. The results show a high level of professional satisfaction and appreciation for the quality of the services provided. In terms of economic impact, the analysis indicates that maintaining VVS, with increased funding and a transition to a more sustainable model, would be less costly in budgetary terms than closing it, considering the potential increase in the costs of hospital emergency services due to lack of access to primary healthcare.

Suggested citation: Barros, P., Villeneuve, O., Matos, N., & Santos, C. (2024). Via Verde Saúde: inovação organizacional em unidades de saúde. Nova School of Business and Economics. https://doi.org/10.34619/xhef-srpy

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The Short Notes series intends to provide analyses on key topics related with the health sector. Based on a survey of the population living in mainland Portugal, which is carried out since 2013 by the Nova School of Business and Economics, this short note analyses children's access to health care. The access reported by respondents from households with children and young people under the age of 15 was used as a proxy for children's access to healthcare, given that children’s access to care depends on household income. Compared to respondents from households consisting only of adults or working age individuals, respondents from households with children under 15 do not appear to face increased financial barriers in accessing healthcare. However, children from the lowest-income households face higher financial barriers in access to health care. Mitigating barriers to children's access to health care involves fighting against poverty – a concern and a need for intervention that goes beyond the health sector.

Suggested citation: Barros, P., & Santos, C. (2023). O Acesso das Crianças a Cuidados de Saúde. Nova School of Business and Economics. https://doi.org/10.34619/eo2j-svk8

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The Short Notes series intends to provide analysis on key topics related with the health sector. This fifth short note explores the conceptual and methodological challenges associated with measuring unmet health care needs.  In 2019, around 40% of Portuguese people with health needs had at least one situation in which they were unable to access healthcare, a figure substantially higher than the European average of 26%, which puts Portugal in an unfavourable position compared to other European countries. The lack of access to healthcare in Portugal is mainly due to financial difficulties, with access to oral health and mental health care being particularly problematic.

Suggested citation: Barros, P., & Costa, E. (2023). Acesso a cuidados de saúde: a medição das necessidades não satisfeitas. Nova School of Business and Economics. https://doi.org/10.34619/msxq-izuf

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The Short Notes series intends to provide analysis on key topics related with the health sector. This fourth short note investigates the individual use of contact tracing apps in the context of the COVID-19 pandemic, based on data collected from an European survey since the beginning of the pandemic. Within the countries included in this study, Portugal displays the lowest rate of download and utilization of such apps during the pandemic. In this short note we discuss three potential channels that affect the success of these apps: the technological landscapes and apps’ features, the individual adherence of each citizen, and the ability to achieve a minimum scale to induce a network effect.

Suggested citation: Barros, P., & Costa, E. (2023). A utilização de Contact Tracing Apps durante a pandemia. Nova School of Business and Economics. https://doi.org/10.34619/vkmo-c49g

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The Short Notes series intends to provide analysis on key topics related with the health sector.

Suggested citation: Barros, P., & Costa, E. (2023). Cuidados centrados no cidadão: tratamento com dignidade, compaixão e respeito. Nova School of Business and Economics. https://doi.org/10.34619/cabo-ktcg

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The Short Notes series intends to provide analysis on key topics related with the health sector. This second short note investigates the evolution of public opinion support for restrictive measures implemented in the context of the COVID-19 pandemic, based on data collected from an European survey since the beginning of the pandemic. Noticeable differences in public opinion support are identified across the seven countries included in the survey. Data suggests that risk perception influences public opinion support for more restrictive measures. Nonetheless, the overall support for restrictive measures in Portugal has been declining over time.

Suggested citation: Barros, P., & Costa, E. (2023). Apoio às medidas do governo no contexto do COVID-19. Nova School of Business and Economics. https://doi.org/10.34619/n8j6-b7fi

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The Short Notes series intends to provide analysis on key topics related with the health sector. This first short note investigates the evolution of trust on government’s information, based on data collected from an European survey since the beginning of the pandemic. Noticeable differences in the trust level are identified across time and across the seven countries included in the survey. More recent data, relative to the beginning of this year, places Portugal as the country with the highest level of trust on government’s information. Moreover, differences can also be identified across age groups. 

Suggested citation: Barros, P., & Costa, E. (2022). COVID-19 e a confiança na informação dos governos. Nova School of Business and Economics. https://doi.org/10.34619/omup-cfbj

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Access to healthcare for the population is a central goal of health systems and a fundamental pillar for equity. This report, based on a representative sample of residents aged 15 or older in mainland Portugal, analyzes the evolution of access to healthcare in the country between 2013 and 2023. Focusing on the decisions made by citizens from the moment they feel ill, the report identifies significant inequalities associated with socioeconomic, demographic, and geographic factors, which undermine equity in the healthcare system.

In 2023, episodes of illness were more frequent among individuals in situations of economic vulnerability, a group that also faces greater difficulties in accessing care. Despite the elimination of most user fees in the National Health Service (NHS) in recent years, financial barriers to accessing healthcare persist, particularly due to the costs associated with prescribed medications. The use of the NHS is approximately ten times higher than that of the private sector, with primary healthcare being the most frequently accessed service, despite a sharp decline in the population with an assigned family doctor in recent years.

The report also includes a groundbreaking generational analysis, highlighting the increased prevalence of chronic diseases among individuals aged 50 and older. While partly explained by greater survival rates and advances in early diagnosis, this increase underscores the urgent need for policies that prevent chronic diseases and ensure that gains in life expectancy translate into more years lived in good health.

Suggested citation: Barros, P., & Santos, C. (2024). Acesso a Cuidados de Saúde 2023 – Uma Década de Evolução. Nova School of Business and Economics. https://doi.org/10.34619/chyu-w4zs

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The Ageing Report analyzes the current and future impact of population ageing on health expenditure and the elderly population's access to healthcare. It evaluates six key dimensions: the impact of ageing on health expenditure; financial protection in old age; access to healthcare for the elderly; active ageing; retirement and healthcare access; and the loneliness pandemic.

Given the profound economic and social implications of population ageing, addressing these challenges demands a concerted effort from health and social protection systems, along with various societal stakeholders. Strengthening social responses to combat elderly poverty and implementing initiatives that promote active ageing are crucial for managing the anticipated increase in the Portuguese population aged 60 and above.

Suggested citation: Barros, P., & Santos, C. (2024). Relatório de Envelhecimento. Nova School of Business and Economics. https://doi.org/10.34619/ipdg-ep4z

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Population's access to healthcare is one of the central objectives of health systems. This report focuses on assessing this access for households with children (under 15) in mainland Portugal. Based on survey data collected since 2013 by the Nova School of Business and Economics, the access of these households is analysed in comparison to households composed only of adults or of working-age people.

Various dimensions of access are explored, including the decision to seek healthcare in the event of an illness, as well as the existence of financial and non-financial barriers. The results show that, when characteristics such as socioeconomic status are considered, households with children do not show significant differences in access to healthcare compared to other households. However, there is a clear socio-economic gradient, indicating that households in more disadvantaged groups are more likely to face barriers to accessing healthcare, regardless of the presence of children in the household.

Suggested citation: Barros, P., & Santos, C. (2024). Acesso das Crianças a Cuidados de Saúde. Nova School of Business and Economics. https://doi.org/10.34619/mcbw-j1jh

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Access to healthcare is among the main concerns of the population regarding health systems functioning and performance. The COVID-19 pandemic has disrupted health systems, with consequences in terms of access to healthcare as well. Based on an annual survey, this report displays the evolution of health care access in Portugal, with a particular focus on the years of 2020 to 2022. Together with past editions, it is possible to analyse key trends since 2013. This report details multiple dimensions of health care access, including disease incidence, the decision to look for health care, access barriers (financial and non-financial), and the public vs private health care provision.

Suggested citation: Barros, P., & Costa, E. (2023). Acesso a Cuidados de Saúde 2022. Nova School of Business and Economics. https://doi.org/10.34619/xag8-b8ku

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Human Resources in the Health Care sector are considered the backbone of Health Systems. The discussion regarding health systems’ challenges implies an analysis of the role that human resources have in the health system. This report presents a set of analysis on multiple challenges affecting health professionals in the Portuguese health system, particularly physicians and nurses. Multiple factors that may contribute to the difficulty on attracting and retaining professionals are discussed in the report. This includes analysis on health professionals ageing, income, dual practice, migration, training capabilities, among others.

Additionally, a discussion on task-shifting and skill-mix is also included to discuss its implications in the Portuguese Health System.

Suggested citation: Barros, P., & Costa, E. (2023). Recursos Humanos em Saúde. Nova School of Business and Economics. https://doi.org/10.34619/fec6-3mrn

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Access to Health Care – Citizens' Choices

Why?
Portuguese society's values on access to health care services are underlined in the Portuguese Constitution and Lei de Bases da Saúde [Health Basic Law]. Little is known about citizens and their decisions on when and how they contact the health care system when they feel sick and before starting their journey within the national health system (in the public or private sector).

How?
Through a population survey with a representative sample of 1271 inhabitants in Portugal over 15. It was the chosen way to learn more about what goes on under the radar of the health system and is not on the National Health Service's record. The GfK company carried out data collection.

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What did we learn?

• There are socioeconomic inequalities when an illness occurs, but there is uniformity when accessing the health care system. Access conditions to the health care system do not enhance these inequalities. The decision to first contact the health care system displays very few obstacles regarding access. When accessing the health care system, impediments are not systematically associated with socioeconomic status within the collected sample (vulnerable populations not captured by these surveys indeed have specific problems). Difficulties occur in case of illness and are not related to health care conditions. From a citizen's perspective, access to the health care system improved, generally, from 2015 to 2020.
• Self-medication is predominant in those who decide not to reach the health care system. Nevertheless, some citizens choose not to go to the health care system when feeling sick (about 10 %), regardless of their socioeconomic status. Of the sample, 63 % chooses to self-medicate. It is essential to learn how and the consequences that it entails.
• There was no "escaping" from the National Health Service to the private sector, nor was the private sector abandoned. There was a reconfiguration within each. When choosing first to contact the health care system, the National Health Service is the leading choice of all socioeconomic groups. The private sector option is clustered in higher socioeconomic classes. Circa 7,3% of those who feel sick have this choice. This proportion rises to 15 % if someone has a higher socioeconomic status.
• In 2020, the "escape" was from hospital emergencies, public and private, to another point of contact of the same industry. The number of people who mentioned a hospital emergency as their first contact with the health care system dropped from 41,1 % in 2019 to 32,2% in 2020 in the public sector and fell from 5 % to 2,1 % in the private sector.
• The main financial difficulties in accessing health care services are associated with medical costs, even though there have been substantial improvements in recent years. The number of people who stopped buying the medical supplies they should, at least once a year, from 2017 to 2020, went from 10,7 % to 5,4 %. However, there are relevant socioeconomic inequalities. This amounted to 2 % in those two years for higher socioeconomic classes and rose from 11 % to 15 % for lower socioeconomic classes. Even though with lower numbers, a similar evolution emerged under the pretext of "not going to an appointment or doing a medical exam due to lack of money" (from 7 % in 2017 to 10 % in 2019 in lower socioeconomic classes).
• For those who opt for the National Health Service when they have an unexpected illness, the main expense is the co-payment of prescribed drugs (average prices range from 21€ on prescriptions to 25€ total for a specific treatment, including user fees and transport, regarding primary health care services. When there is a hospital emergency, expenses amount to 24€ in prescriptions and 36€ total).
• In 2020, there are two new "access obstacles" – the fear of reaching out to the health care system due to COVID-19, which was referred by 15 % of people, and having the health service provider cancel the appointment at his own initiative, referred to by 20 % of the people interviewed. Older people and people with lower socioeconomic status stated to have more fear. Cancellations under the provider's initiative affected all socioeconomic classes equally. The elderly, who usually have more medical appointments, were the ones who were more affected. Despite the fear, people still trust health care services (those who were more isolated during the pandemic are no longer afraid of going to the health care system).
• Three out of four people feel they have been treated with dignity, compassion, and respect by the health care system's services. Even though there is a global number of 76,6%, in 2020, people who mentioned that they were treated with dignity, compassion, and respect, there were differences in said treatment associated with their level of education – 80% of people with basic levels of education to 72 % with higher education. Similar assessments in England show numbers ​​above 80 % and close to 90 % regarding specific health services.

What needs to get better?

• Get to know the self-medication of those who do not seek the health system better
• Improve the financial protection in medicine consumption
• Improve the human aspect of the health care system's provision
• Consolidate the primary health care response and its planned use

• Risk communication during COVID-19: A descriptive study on familiarity with, adherence to and trust in the WHO preventive measures, Nirosha Elsem Varghese, Iryna Sabat, Sebastian Neumann-Böhme, Jonas Schreyögg, Tom Stargardt, Aleksandra Torbica, Job van Exel, Pedro Pita Barros, Werner Brouwer, Plos one 16 (4), e0250872
• Blood donation in times of crisis: Early insight into the impact of COVID‐19 on blood donors and their motivation to donate across European countries, Torsten Chandler, Sebastian Neumann‐Böhme, Iryna Sabat, Pedro Pita Barros, Werner Brouwer, Job van Exel, Jonas Schreyögg, Aleksandra Torbica, Tom Stargardt, Vox Sanguinis
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• Simplified Mathematical Modelling of Uncertainty: Cost-Effectiveness of COVID-19 Vaccines in Spain, Julio Emilio Marco-Franco, Pedro Pita-Barros, Silvia González-de-Julián, Iryna Sabat, David Vivas-Consuelo, Mathematics 9 (5), 566
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• United but divided: Policy responses and people's perceptions in the EU during the COVID-19 outbreak, Iryna Sabat, Sebastian Neuman-Böhme, Nirosha Elsem Varghese, Pedro Pita Barros, Werner Brouwer, Job van Exel, Jonas Schreyögg, Tom Stargardt, Health Policy 124 (9), 909-918