Abstract
Background: the global healthcare landscape is shifting towards a paradigm of value-based care, emphasizing patient outcomes, efficiency, and patient-centeredness. Portugal is ready to embrace this transformation, especially with the generalization of the model of formal integration of primary care with hospital care, the Local Health Unit (ULS). Primary health care (PHC) in Portugal, recognized for its robustness in European comparisons, today faces challenges to ensure seamless integration with hospital care, involving patients, communities, and professionals. Internationally there have been advances in PHC performance assessment, however there is still an excessive focus on costs and on the volume of provision.
Methods: the purpose of this narrative review is to assess the current state of PHC performance evaluation in Portugal, to gauge whether there is a need to improve existing models. Relevant literature on performance evaluation in primary care (Leykum, 2023; WHO, 2020; EU, 2018) and the existing public documentation in Portugal for contractualisation in PHC were reviewed.
Results: In Portugal, there have been developments in PHC evaluation, with the introduction of payment by performance and the incorporation of indicators that incentivise improved access to this level of care; disease prevention, health promotion and surveillance of chronically ill patients; patient and professional safety and patient satisfaction. Even so, as is still the international standard, there continues to be a focus on costs and volume of provision, creating a cycle of resource depletion and undermining trust in the health system. In terms of assessing patient satisfaction, there is no uniform assessment tool to be adopted, nor is there a definition of the methodologies for collecting and analysing data; still in terms of patient satisfaction, a set of dimensions and results that are of interest to patients are still not being considered. In terms of professional satisfaction, it is also unclear how the evaluation is carried out, as well as the degree of involvement of professionals in this process and the impact on their performance. Also, nothing has been found concerning the value of networks and programmes in the community, a dimension that is seen as relevant to integrate and evaluate. Some national PHC experiences, which provided for innovative collaborative models, have been identified, however their results and the evaluation model are not public.
Conclusion: In Portugal, although some progress has already been made, there continues to be an excessive focus on costs and the volume of provision and less on the real value created. It would be important to systematise and standardise both the instruments and the evaluation methodologies adopted in PHC, to facilitate evaluation and comparison processes, as well as integrate value-based dimensions, relevant for patients, professionals, and communities.
References:
European Commission. (2018). A new drive for primary care in Europe: Rethinking the assessment tools and methodologies-report of the expert group on health systems performance assessment.
Leykum, L. K. (2023). Reconceptualizing Primary Care: From Cost Center to Value Center. NEJM Catalyst Innovations in Care Delivery, 4(5).
World Health Organization. (2020). Operational framework for primary health care: transforming vision into action.
This work was financially supported by the Research Unit on Governance, Competitiveness and Public Policies (UIDB/04058/2020) + (UIDP/04058/2020), funded by national funds through FCT - Fundação para a Ciência e a Tecnologia.