1.  Portuguese health policies evolved considerably over the last fifty years

Up to the mid 70´public health action was oriented towards specific diseases (such as tuberculosis and those preventable by immunization) of population groups particularly at risk (such as mothers and children).  There was a specific Mental Health Institute.

By the mid/late 70's health policies were channelled through primary health care and the "health centre" movement, and later by the NHS ideals and organisational arrangements. Institutional planning became mandatory, but was often administrative obligation than a tool to manage change.

From the mid 80's to the mid 90's the "community settings" approach and the principles of health promotion played an important role in the development of the Portuguese healthy cities and healthy schools networks.

Only between 1996 and 1999 an explicitly targeted health strategy was produced, revised, discussed and finally adopted in 1999: "Health, a commitment - a health strategy for the turn of the century (1998-2002)".

This document identifies 27 major health areas for action (from aging and active living to depression and school health) in addition to health services access and quality, health professions, health financing, resource management, information knowledge and communication, European and international cooperation. For each of this areas 5 year quantitative targets and 10 years qualitative or quantitative targets were established and broad action orientations for achieving them were identified. The 5 Health Regions of the country developed accordingly their health strategies on a more operational basis. Local actors were stimulated to use this strategic framework to establish and achieve their own targets. Final agreement on the monitoring and evaluation exercises regarding this Health Strategy was to take place by the end of 1999. As  a new Ministerial team took office by the end of 1999, this health strategy lost political support.

Currently the Ministry of Health is preparing new strategic orientations for improving - a "Health Plan" – that after a process of broad consultation process, in close cooperation with WHO and the EU, is expected to be adopted early 2004.     

2.  Implementing health care reforms is a major challenge anywhere.

Complete or partial lack of implementation of health care reform legislation has been frequent in the past. Some significant examples can be easily recalled.

The 1971 reform legislation was meant to integrate public health centres and social security clinics into one primary health care network. This only took place only approximately 12 years later, 5 year after the NHS legislation dwelt into this same point.

The 1979 NHS legislation pointed to the need of a central NHS management structure. This was never implemented. Currently the central health administration is still fragmented into a considerable number of directorates and institutes difficult to coordinate and to provide an appropriate central interface to regional health administrations.

The 1990 new general health legislative framework ("basic health law") was only translated into compatible NHS legislation in 1993 and into one of its more significant thrusts – private management of public institutions – with a single experiment in 1995.

More recently, the 1999 health legislation concerning the establishment of "local health systems" and primary health care reform was not implemented nor substituted by something different during the following 2 to 3 years.

Difficulties in implementation of health care reforms may be attributed to many different factors. In Portugal five key factors impairing health care reform implementation can be identified Portuguese Health Systems Observatory, 2001, 2002, 2002):

·         Poorly knowledge based decisions.

Difficulties and limitations in designing and implementing evidence based policies are well known. Very few of the most important health care reform initiatives in Portugal have been preceded by analytical documents, detailing the evidence base of proposed changes, establishing expected outcomes in an objective and quantitative way, framing clearly the impact assessment approach to be adopted or benefiting from broad technical and public debates. The absence of such base line references severely impairs monitoring and evaluation prospects and therefore weakens effective implementation

·         Normative tradition

Management of change has strong normative tradition in Portugal. Legislation is seen as kick-off mechanisms in the process of change rather than a facilitating and reinforcing tool for successful field experiences. This tradition tends to underplay the importance of the cultural, educational and managerial elements of the processes of change.

·         Command-and-control administration

This has been a predominant feature of the Portuguese health system.  The limited role played by policy and managerial information systems in decision making make policy implementation an hazardous exercise.

·         Health policy discontinuity.

Severe health policy discontinuities have been observed over the last twenty years in Portugal. This not limited to natural changes of political cycles but is also very much seen in Ministerial changes within the some government. These discontinuities have been a predominant factor in making health care reform implementation difficult in Portugal.

·         Governance limitations and resistance to change

A good governance approach to management of change has yet to be applied in Portugal

Current emphasis on implementation may mean that some of these lessons from the past has been taken into account. However detailed analysis of reforms evidence base and its public debate are still limited.

3.  The social and economic condition of Portugal experienced extraordinary progress in the last thirty years. Improvement in health status and health services reflects to a large extent these broader societal developments.

4.  In some areas Portugal has done better than what one would expect from its social and economic development indicators.

The Portuguese immunization programme has been a very successful one since its inceptions in the 60's. It has been developed in a way that ensured over a long period of time strong and sustained support from health professions and the community at large. This explains Portugal's high immunization rates by European standards.