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The Portuguese health system has the peculiar characteristic of being a Beveridge-Bismarck type aiming at universal coverage. On top of the national health system coverage, there is a second coverage provided to some professionals, plus a third layer of coverage that can be acquired by taking out voluntary private health insurance. The aim of this work is to ascertain whether people benefiting from supplemental multi-layer health coverage (on top of the existing National Health System) have more consultations, either with general practitioners or with specialists, and enjoy better health status. We used data from the National Health Survey from 2014 to estimate a recursive system of ordered probits. The main results confirm that multi-layer health coverage is correlated with the use of more specialist consultations, but not with more GP consultations. It is also correlated with better health status. These results may indicate the existence of moral hazard, induced demand and/or 'access effect'. Regarding policy matters, the measures aimed to reduce waiting times, improve patient choice, and increase access could counteract such results and mitigate the potential inequity of access and health status, and also excessive use of medical services that can happen under double health coverage.

The Portuguese National Health System is composed of all public entities offering health services. There has been a successive increase in expenditure in recent years due to various factors that have contributed to a high degree of uncertainty about the evolution of operating costs in Public Business Hospitals. This research's main objective is to study the relationship between operational costs and waiting times as well as costs with healthcare professionals and waiting times in both external consultations and hospital surgeries. Furthermore, we will empirically assess the presence of U-shaped behaviour in both of these two relationships. We have included a sample of 38 hospitals considered in the Portuguese National Health System. We also included, in our analysis, five groups of public business hospitals, according to the Administrative Central Agency of Portugal's Health Service, considering the period between January 2015 and December 2019. To validate the two relationships proposed, the Autoregressive Distributed Lag panel model was used. This study highlights that longer waiting times for external consultation and surgery significantly affect hospital costs and suggest that longer waiting times do not merely increase absence rates. The study also proves that there are long-term effects that last beyond the short-term waiting period., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Cancer has affected around eighteen million people all over the world in 2018. In Portugal, cancer was diagnosed in sixty thousand individuals during 2018, being the second leading cause of death (one in every four deaths). Following the European Directive 2011/24/EU, the Portuguese Health System has been recognizing oncology Reference Centres (RCs), which are focused on delivering best-in-class treatment for cancer patients. This paper performs a survival analysis of cancer patients in Portugal, having hospital episodes with discharge date after the official recognition, in 2016, of the first RCs for hepatobiliary, pancreatic, sarcomas and oesophageal cancer. The aim is to assess the impact of RCs on the survival probability of these patients. For each cancer type, survival curves are estimated using the Kaplan-Meier methodology, and hazard ratios are estimated for different covariates, using multivariate Extended Cox models. The results obtained support the implementation and encourage the further extension of the RC model for oncology in Portugal, as cancer patients treated in an oncology RC, overall, have a better survival probability when compared to patients who had no episode in an RC. These results are clearer for hepatobiliary and pancreatic cancer, but also visible for sarcomas and oesophageal cancer., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

This paper aims to investigate if the market structure reforms in the Portuguese health system have improved hospital performance and productivity. A robust non-parametric Malmquist index is applied to measure group performance. The significance of the results achieved is examined using a conditional and non-conditional subsampling bootstrapped-based methodology, enhanced by the likelihood cross validation criterion based on the k-nearest neighbors method. The sample contains information about 216 non-corporatized and 176 corporatized Portuguese hospitals for the period 2002–2009. Five models were applied, based on three study dimensions (internment, emergencies and doctor visits). The results show that although corporatized hospitals presented the highest efficiency consistency, they had also the lowest levels of productivity, while the hospitals under the traditional administrative public management system were the ones with the best average performance. However, several best practices were also found in all groups, being the limited companies were often dominated by both noncorporatized and public enterprise entities. Consistent output ranges where all groups present dominance over the others were also identified. It was possible to conclude that the more autonomy the hospital had from the Ministry of Health, the lower was its productivity.

In this paper, we evaluate the effect of demand uncertainty on hospital costs. Since hospital managers want to minimize the probability of not having enough capacity to satisfy demand, and since demand is uncertain, hospitals have to build excess capacity and incur the associated costs. Using panel data comprising information for 43 Portuguese public hospitals for the period 2007-2009, we estimate a translog cost function that relates total variable costs to the usual variables (outputs, the price of inputs, some of the hospitals' organizational characteristics) and an additional term measuring the excess capacity related to the uncertainty of demand. Demand uncertainty is measured as the difference between actual and projected demand for emergency services. Our results indicate that the cost function term associated with the uncertainty of demand is significant, which means that cost functions that do not include this type of term may be misspecified. For most of our sample, hospitals that face higher demand uncertainty have higher excess capacity and higher costs. Furthermore, we identify economies of scale in hospital costs, at least for smaller hospitals, suggesting that a policy of merging smaller hospitals would contribute to reducing hospital costs.

This paper revisits the debate on health and economic growth (Deaton in J Econ Lit 51:113-158, 2003) focusing on the Portuguese case by testing the relationship between growth and health. We test Portuguese insights, using time series data from 1960 to 2005, taking into account different variables (life expectancy, labour, capital, infant mortality) and considering the years that included major events on the political scene, such as the dictatorship and a closed economy (1960-1974), a revolution (1974) and full democracy and an open economy (1975-2005), factors that influence major economic, cultural, social and politic indicators. Therefore the analysis is carried out adopting Lucas' (J Monet Econ 22(1):3-42, 1988) endogenous growth model that considers human capital as one factor of production, it adopts a VAR (vector autoregressive) model to test the causality between growth and health. Estimates based on the VAR seem to confirm that economic growth influences the health process, but health does not promote growth, during the period under study.

This long-term study (2003-2010) compared the breeding parameters of great tits living in a paper-and-pulp-industry area to those of great tits living in a rural area on the west coast of Portugal. We also measured the abundance of caterpillar biomass, an important food source and determinant of breeding success for tits. In 2009, we further analysed trace metal [arsenic (As), calcium (Ca), cadmium, copper, mercury (Hg), nickel, lead, selenium, and zinc] as well as Ca concentrations in excrement of 15-day-old great tit nestlings. Generally, for most trace metals, fecal concentrations were similar at both sites. Nonetheless, greater Hg levels and lower As levels were detected in the industrial area. Great tits laid more eggs and produced more fledglings in the industrial area than in the rural area. Caterpillar biomass was also greater in the industrial area, which likely explains the better breeding success. Our results suggest that there are no direct effects of emissions on the studied species.

Studies of late stages of Parkinson's disease (LS-PD) are limited. To provide an adequate health plan for patients in these most advanced stages, accurate information on their clinical condition is necessary. We characterize clinical features and medication use of LS-PD. A cross-sectional study of LS-PD stage 4 or 5 of Hoehn and Yahr during on states is presented in this paper. Demographics, clinical features and medication data were obtained using a structured questionnaire and physical examination. Patients were asked to grade the perceived impact of symptoms on their health status. Fifty patients (mean age 74.1 years and mean disease duration 17.9 years) were studied. Severe akinetic symmetric parkinsonism was present in most, with negligible rigidity and tremor, and most patients were wheelchair-bound. Severe postural instability and freezing of gait, causing frequent falls and fractures, and prominent dysarthria and dysphagia dominated the motor syndrome. Levodopa remained effective in most patients in relieving motor symptoms including tremor. Motor fluctuations and dyskinesias were present in 78 and 62% of patients, respectively, but were not perceived as disabling. All had neuropsychiatric and dysautonomic symptoms. Visual hallucinations were present in 44%, depression in 62% and dementia in 50%. Lack of tremor (p < 0.01) and absence of depression (p < 0.01) were independently associated with dementia (R(2) = 45%). Symptoms causing greatest impact on perceived health status were falls, gait unsteadiness, urinary dysfunction and sweats. Motor and non-motor non-levodopa responsive problems were frequent and the main cause of disability. Fluctuations and dyskinesias were frequent though not disabling. Dementia is not unavoidable in these very late stages.

The main goals of this paper are to (1) analyse the inequality in geographic distribution of physicians and its evolution, (2) estimate the determinants of physician density, and (3) assess the importance of competitive and agglomerative forces in location decisions. The analysis of the geographic distribution of physicians is based on the ratio of general practitioners (GPs) and specialists to 1,000 inhabitants. The inequality is measured using Gini indices, coefficients of variation, and physician-to-population ratios. The econometric models were estimated by ordinary least squares. The data used refer to 1996 and 2007. The impact of the growing number of physicians, and therefore potential increased competition, on geographic distribution during the period studied was small. Nonetheless, there is evidence of competitive forces acting on the dynamics of doctor localisation. Geographic disparities in physician density are still high, and appear to be due mainly to geographic income inequality.

HIV/AIDS disproportionately affects sub-Saharan Africa and 90% of the children with HIV are found there. In addition, non-HIV-infected children in the region are also vulnerable with an estimated 11.4 million AIDS orphans (many of whom are also HIV-positive). South Africa has an estimated 5.5 million people infected with HIV, which is by far the highest in the world. South Africa was reluctant to accept international assistance and began to provide care and treatment much later than its neighbours, and access to care and treatment remains low. Only 36% of children with advanced AIDS living in South Africa were receiving antiretroviral drugs in 2007. This paper not only provides data expressing the extent of the HIV problem affecting children, but also compares neighbouring African countries' successes and failures in combating the disease.