The effects of austerity measures on quality of healthcare services: a national survey of physicians in the public and private sectors in Portugal

Correia et al. Human Resources for Health (2017) 15:82 DOI 10.1186/s12960-017-0256-6 RESEARCH Open Access The effects of austerity measures on quality of healthcare services: a national survey of physicians in the public and private sectors in Portugal Tiago Correia1*, Graça Carapinheiro1, Helena Carvalho1, José Manuel Silva2 and Gilles Dussault3 Abstract Background: The European Union member countries reacted differently to the 2008 economic and financial crisis. However, few countries have monitored the outcomes of their policy responses, and there is therefore little evidence as to whether or not savings undermined the performance of health systems. We discuss the situation in Portugal, where a financial adjustment program was implemented between 2011 and 2014, and explore the views of health workers on the effects of austerity measures on quality of care delivery. Methods: A nationwide survey of physicians’ experiences was conducted in 2013–2014 (n = 3442). We used a two-step model to compare public and private services and look at the possible moderating effects of the physicians’ specialty and years of practice. Our data analysis included descriptive statistics, the independent t test, analysis of variance (ANOVA), multivariate logistic regression, General Linear Model Univariate Analysis, non-parametric methods (bootstrap), and post hoc probing. Results: Mainly in the public sector, the policy goal of maintaining quality of care was undermined by a lack of resources, the deterioration in medical residency conditions, and to a lesser extent, greater administrative interference in clinical decision-making. Differences in public and private services showed that the effects of the austerity measures were not the same throughout the health system. Our results also showed that physicians with similar years of practice and in the same medical specialty did not necessarily experience the same pressures. Conclusions: The debate on the effects of austerity measures should focus more closely on health workers’ concrete experiences, as they demonstrate the non-linearity between policy setting and expected outcomes. We also suggest that it is necessary to explore the interplay between lower quality and the undermining of trust relationships in health. Keywords: Portugal, Economic crisis, Adjustment programs, Austerity measures, Quality of care, Trust Background Crises and health system performance: where do we stand in the debate? How health services are planned, purchased, and delivered has a direct impact on the key dimensions of health system performance, i.e., efficiency, quality, and access [1]. In the aftermath of the economic and financial crisis that hit most member countries of the European Union, * Correspondence: 1 School of Sociology and Public Policies, ISCTE-Instituto Universitário de Lisboa, Av Forcas Armadas, 1649-026 Lisbon, Portugal Full list of author information is available at the end of the article the question is raised of whether the impact of cuts in public funding and other austerity measures had neutral effects or have undermined the performance of health services [2]. As the crisis grew in intensity, the WHO Regional Office for Europe [3] recommended that member states monitor the effects of their policy responses on health indicators. Few countries did so, and existing assessments have focused mainly on measuring changes in access and efficiency, thus the need for further evidence on the dimension of quality of care delivery [4]. © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Correia et al. Human Resources for Health (2017) 15:82 The analysis of health services delivery needs to take into account that the operation of provider organizations is more complex than assumed by political decisionmakers [5]. This premise is based on the neoinstitutional literature that argues that macro-level policies are affected by workplace-level contingencies that produce “perverse or non-expected” effects [6, 7]. This has received little attention in the debates on the effects on the quality of health services of political responses to the crisis. This paper is a contribution to the debate through a deeper look at how different levels of care, e.g., hospital and primary care, and the internal stratification of the medical profession, e.g., by specialty and years of service, constitute such contingencies [8–10]. That may explain why various categories of physicians, working in different environments, have reacted differently to the pressures generated by policy responses to the crisis. Additionally, although public services have been the main target of austerity measures, complementarity with the private sector and growing pressure for marketization in many countries [11] raises the issue of understanding better how private providers have adapted to the economic crisis. There has not yet been systematic research into this matter even though some authors suggest that public regulation can be less effective in monitoring and penalizing for-profit investors for patient selection [12]. The situation in Portugal In 2011, a Memorandum of Understanding (MoU) between the Portuguese Government and the International Monetary Fund, The European Central Bank, and the European Commission designed a €78 billion, 3-year financial adjustment program with specific timelines and policy targets to reduce the budget deficit from 9.8 to 3% of GDP in 2013. Cost containment in the health sector was considered feasible without undermining the quality of services [13]. Direct cuts in the health sector were initially estimated at €550 million. However, they doubled after 1 year and reached €1.3 billion in 2013 [14]. Specific health-related policies were aimed at different targets: more cost-sharing, better drug-market regulation, tighter control over physicians’ prescribing and of the management of public provider organizations, more transparent public-private partnership, expansion of primary health care services, and savings on workforce costs. Table 1 shows the extent to which these objectives were achieved. Overall, the massive reduction in public expenditure came more from cost-sharing, tighter drug-market regulation, control over prescribing, and of the management of provider organizations. Improvements in publicprivate partnership, better access to primary healthcare, and workforce changes contributed to a lesser extent (...truncated)