The Portuguese NHS 2024 reform: transformation through vertical integration.

Vertical integration models aim for the integration of services from different levels of care (e.g., primary, and secondary care) with the objective of increasing coordination and continuity of care as well as improving efficiency, quality, and access outcomes. This paper provides a view of the Portuguese National Health Service (NHS) healthcare providers' vertical integration, operationalized by the Portuguese NHS Executive Board during 2023 and 2024. This paper also aims to contribute to the discussion regarding the opportunities and constraints posed by public healthcare organizations vertical integration reforms. The Portuguese NHS operationalized the development and generalization of Local Health Units management model throughout the country. The same institutions are now responsible for both the primary care and the hospital care provided by public services in each geographic area, in an integrated manner. This 2024 reform also changed the NHS organic and organizational structures, opening paths to streamline the continuum of care. However, it will be important to ensure adequate monitoring and support, with the participation of healthcare services as well as community structures and other stakeholders, to promote an effective integration of care.

Modeling the health impact of legislation to limit the salt content of bread in Portugal: A macro simulation study.

Background: Excessive salt consumption-associated with a range of adverse health outcomes-is very high in Portugal, and bread is the second largest source. Current Portuguese legislation sets a maximum limit of 1.4 g salt per 100 g bread, but imported and traditional breads are exempted. In 2017 the Ministry of Health proposed reducing the salt threshold to 1.0/100 g by 2022, however the legislation was vetoed by the European Commission on free-trade grounds. Aims: To estimate the health impact of subjecting imported and traditional breads to the current 1.4 g threshold, and to model the potential health impact of implementing the proposed 1.0 g threshold. Methods: We gathered bread sales, salt consumption, and epidemiological data from robust publicly available data sources. We used the open source WHO PRIME modeling tool to estimate the number of salt-related deaths that would have been averted in 2016 (the latest year for which all data were available) from; (1) Extending the 1.4 g threshold to all types of bread, and (2) Applying the 1.0 g threshold to all bread sold in Portugal. We used Monte Carlo simulations to generate confidence intervals. Results: Applying the current 1.4 g threshold to imported and traditional bread would have averted 107 deaths in 2016 (95% CI: 43-172). Lowering the current threshold from 1.4 to 1.0 g and applying it to all bread products would reduce daily salt consumption by 3.6 tons per day, saving an estimated 286 lives a year (95% CI: 123-454). Conclusions: Salt is an important risk factor in Portugal and bread is a major source. Lowering maximum permissible levels and removing exemptions would save lives. The European Commission should revisit its decision on the basis of this new evidence.

The Ethics of Taxing Sugar-Sweetened Beverages to Improve Public Health.

The World Health Organization highlights fiscal policies as priority interventions for the promotion of healthy eating in its Action Plan for the Prevention and Control of Non-communicable Diseases. The taxation of sugar sweetened beverages (SSBs) in particular is noted to be an effective measure, and SSBs taxes have already been implemented in several countries worldwide. However, although the evidence base suggests that this will be effective in helping to combat rising obesity rates, opponents of SSBs taxation argue that it is illiberal and paternalistic, and therefore should be avoided. Bioethical analysis may play an essential role in clarifying whether policymakers should adopt SSBs taxes as part of wider obesity strategy. In this article we argue that no single ethical theory can account for the complexities inherent in obesity prevention strategy, especially the liberal theories relied upon by opponents of SSBs taxation. We contend that a pluralist approach to the ethics of SSBs taxation must be adopted as the only suitable way of accounting for the multiple overlapping, and sometimes, conflicting factors that are relevant to determining the moral acceptability of such an intervention.

Projected impact of the Portuguese sugar-sweetened beverage tax on obesity incidence across different age groups: A modelling study.

BACKGROUND: Excessive consumption of sugar has a well-established link with obesity. Preliminary results show that a tax levied on sugar-sweetened beverages (SSBs) by the Portuguese government in 2017 led to a drop in sales and reformulation of these products. This study models the impact the market changes triggered by the tax levied on SSBs had on obesity incidence across various age groups in Portugal. METHODS AND FINDINGS: We performed a national market analysis and population-wide modelling study using market data for the years 2014-2018 from the Portuguese Association of Non-Alcoholic Drinks (GlobalData and Nielsen Consumer Panel), dietary data from a national survey (IAN-AF 2015-2016), and obesity incidence data from several cohort studies. Dietary energy density from SSBs was calculated by dividing the energy content (kcal/gram) of all SSBs by the total food consumption (in grams). We used the potential impact fraction (PIF) equation to model the projected impact of the tax-triggered change in sugar consumption on obesity incidence, through both volume reduction and reformulation. Results showed a reduction of 6.6 million litres of SSBs sold per year. Product reformulation led to a decrease in the average energy density of SSBs by 3.1 kcal/100 ml. This is estimated to have prevented around 40-78 cases of obesity per year between 2016 and 2018, with the biggest projected impact observed in adolescents 10 to <18 years old. The model shows that the implementation of this tax allowed for a 4 to 8 times larger projected impact against obesity than would be achieved though reformulation alone. The main limitation of this study is that the model we used includes data from various sources, which can result in biases-despite our efforts to mitigate them-related to the methodological differences between these sources. CONCLUSIONS: The tax triggered both a reduction in demand and product reformulation. These, together, can reduce obesity levels among frequent consumers of SSBs. Such taxation is an effective population-wide intervention. Reformulation alone, without the decrease in sales, would have had a far smaller effect on obesity incidence in the Portuguese population.

Financial Crisis in Portugal: Effects in the Health Care Sector.

Portugal has faced an economic and financial crisis that began circa FY2009 and whose effects are still ongoing. In FY2011, the Portuguese state and the European triumvirate - composed of the European Commission, the International Monetary Fund, and the European Central Bank - signed the Memoranda of Understanding. This troika agreement aimed to improve the operational efficiency of public services. This crisis had a considerable impact on the Portuguese citizens' life and productivity, as well as on the public health care system. Cuts over public expenditures have been made to reduce the risk of noncompliance with budgetary targets, despite their potential impact on quality and access to health care services. We analyzed the main policies and measures undertaken by the Portuguese Ministry of Health with respect to the bailout program associated with the troika agreement. Then, we focused on the budgetary cuts-related risks over the social performance of the care system. Evidence suggests that structural reforms in the health care sector in the troika period had positive effects in terms of drugs administration and consumption, on the one hand, and secondary care expenditures reduction, on the other hand. Nonetheless, we observed some divestitures on infrastructures and the worsening of access to health care services.