Research

Abstract

Primary care is an essential pillar of health systems. Many countries have implemented different policies to improve access to primary care. However, persistent challenges remain. This paper offers a critical analysis of the evolution of primary care coverage in Portugal, focusing on the number of patients without an assigned general practitioner (GP).

We collected and analyzed publicly available data from 2009 to 2023 to decompose primary care coverage in three components: the number of patients enrolled in primary care units (demand-side effect), the number of GPs measured in full-time equivalent (supply-side effect), and the average number of patients on each GP’s list (patient-to-GP ratio, capturing a productivity effect). We provide national and local level estimates for these three components.

Between 2009 and 2023, there was an overall decline in the number of patients enrolled in primary health care units. Concurrently, there was also a net decrease of GPs measured in full-time equivalent. Additionally, there was a progressive reduction in the average number of patients on each GP’s list. The rise in the number of patients without an assigned GP is attributed not only to a reduction in the number of physicians, but also to a decrease in the patient load per doctor.

Hiring additional GPs may not suffice to enhance coverage. Achieving higher coverage may imply revisiting patient load per doctor or considering alternative care models. Understanding the challenges related to GP coverage is critical for improving the efficiency of primary care.

Abstract

Abstract

This study has the aim of assessing the Brazilian perceptions, influencing factors and political positioning on the confidence concerning COVID-19 vaccination. To achieve the objective, the methods rely on a cross-sectional survey of Brazilian citizens, distributed through different social networks. The sample is composed of 1,670 valid responses, collected from almost all Brazilian states and state capitals. To analyze the data and give a clear view of the variables’ relationship, the study used bivariate and comparative graphs. Results show a higher level of confidence in vaccines from Pfizer and AstraZeneca, while the lower level of confidence is associated with vaccines from Sinopharm and Sputinik5. Vaccine efficacy is the most significant influencing factor that helps in the decision to get vaccinated. Also, individuals are less willing to get vaccinated if their political preferences are related to the right-wing. The results led to three main health and social implications: i) the vaccination strategy campaigns should take in count vaccine efficacy and political aspects; ii) the vaccination process should be adapted to regions with different political positions; and iii) a reinforcement in the educational policies of the vaccine’s importance to the public health, to avoid the politization of a health issue.

Abstract

Many countries are facing challenges in recruiting and retaining physicians, particularly in regions where the public and private sectors compete for doctors. Understanding the factors influencing physicians’ job choices can help inform policies aimed at attracting and retaining this valuable workforce. This study aims to elicit the strength of physicians' preferences regarding various job-related aspects, including earnings, time flexibility, discussion of clinical cases, frequency of facilities and equipment updates, training opportunities and autonomy in decision making.

To achieve this, a Discrete Choice Experiment (DCE) was administered to 697 physicians. Each participant completed a series of eight choice tasks, where they had to choose between two hypothetical jobs differing in these attributes with levels mirroring positions in the public and private sectors in Portugal. The resulting choices were analysed using mixed logit, generalized multinomial logit and latent classes models to account for diverse unobserved variations in physicians' preferences and to explore preference heterogeneity across different observable characteristics.

Jobs that offered more autonomy and training opportunities were strongly preferred, as physicians would require additional compensation to work with reduced autonomy (equivalent to 28.62% of gross income) or less frequent training (equivalent to 22.75%). This study also shows that the ranking of the job characteristics is similar between physicians working exclusively in the public sector and those engaged in dual practice. Nevertheless, public sector physicians place more emphasis on the availability of frequent training possibilities and frequent updates of facilities and equipment compared to their counterparts in dual practice.

These findings contribute to existing knowledge by highlighting the significance of non-monetary attributes and shedding light on the preferences of physicians across various employment scenarios. They offer valuable insights for policy development aimed at influencing physicians' allocation of time between sectors.

Abstract

Unplanned critical care admissions following in-hospital deterioration in children are expected to impose a significant burden for carers among different dimensions. One dimension relates to the financial and economic impact associated with the admission, from both direct out-of-pocket expenditures, as well as indirect costs, reflecting productivity losses. A robust assessment of these costs is key to understand the impact of interventions aiming at reducing in-patient deterioration. This work aims to determine the economic burden imposed on families caring for hospitalised children that experience critical deterioration events.

Descriptive study with quantitative approach. Carers responded to an online survey between July 2020 and April 2021. The survey was developed by the research team and piloted before use. The sample comprised 71 families of children admitted to a critical care unit following in-patient deterioration, at a tertiary children’s hospital in the UK. The survey provides a characterization of the carer’s household and estimates of direct non-medical costs grouped in five different expenditure categories. Productivity losses can also be estimated based on the reported information.

Two-thirds of working carers had missed at least one workday in the week prior to the survey completion. Moreover, eight in ten carers reported having had to travel from home to the hospital at least once a week. Most carers reported expenditures associated to the child’s admission in the week preceding the survey completion. These expenditures, on average, amount to £166 per week, grouped in five categories (38% each to travelling costs and to food and drink costs, with accommodation, childcare, and parking representing 12%, 7% and 5%, respectively). Additionally, weekly productivity losses for working carers are estimated at £195.

Unplanned critical care admissions for children impose a substantial financial burden for carers. Moreover, productivity losses imply a subsequent cost to society. Even though subsidised hospital parking and on-site accommodation at the hospital contribute to minimising such expenditure, the overall impact for carers remains high. Interventions aiming at reducing emergency critical care admissions, or their length, can be crucial to further contribute to the reduction of this burden.

Abstract

Patients’ monitoring systems have been implemented in critical care units to prevent critical deterioration events (CDE). However, implementation of similar technologies for children in hospitals is subject to additional concerns. Even though these systems may be seen as a promising path, their impact on costs remains unclear. In this study we provide evidence on the potential direct cost savings arising from the implementation of DETECT - which contributes to reduce CDE in paediatric patients.

Data was collected at a tertiary children’s hospital in the United Kingdom. We rely on the comparison between patients in the baseline period (March 2018 to February 2019) and patients in the post-intervention period (March 2020 to July 2021). A total of 19,562 hospital admissions were recorded for each group (matched cohort). From these admissions, 332 and 286 CDEs were observed in the baseline and post-intervention period, respectively. Hospital reported costs and Health Related Group (HRG) tariffs were used to estimate overall expenditure associated with the CDE for both groups of patients.

In the baseline period, daily average reported costs for CDE based on HRG costs amounts to £2,200. Comparing the post-intervention with the baseline data, one observes a reduction in the total number of critical care days. This reduction leads to a cost reduction that ranges between £0.99 and £1.19 million (13.2% and 13.6% relative to the baseline cost). These cost reductions are driven by an overall reduction in CDE and not by a reduction in the unit cost of each CDE.

Unplanned critical care admissions for children impose a substantial burden on patients and families but are also costly for hospitals. Interventions aiming at reducing emergency critical care admissions can be crucial to contribute to the reduction of these episodes’ costs. Results support the hypothesis that reducing CDEs, using technology, has a direct impact on hospital costs.

Abstract

Trust in institutions is a key driver to shape population attitudes and behavior, such as compliance of non-pharmaceutical interventions (NPI). During the COVID-19 pandemic, this was fundamental and its compliance was supported by governmental and non-governmental institutions. Nevertheless, the situation of political polarization in some countries with  fragmented health systems  increased the difficulty of such interventions. This study analyzes the association between non-pharmaceutical interventions’ compliance and individual perception regarding institutions’ performance during the COVID-19 pandemic in Brazil. A web survey was conducted in Brazil between November 2020 and February 2021. Bivariate analysis and ordered logit regressions were performed to assess the association between NPIs compliance and perceived institutions’ performance. Results suggest a negative association between NPIs’ compliance and Federal Government and Ministry of health perceived performance, which may reflect the political positioning of the respondents. Moreover, we find a positive association between NPI compliance and the perceived performance of the remaining institutions (state government, federal supreme court, national congress, WHO, media and SUS). Our contribution goes beyond the study of a relationship between non-pharmaceutical interventions’ compliance and institutions’ performance, by pointing out the importance of subnational and local governmental spheres in a decentralized health system, as well as highlighting the importance of social communication based on health organizations’ information and scientific institutions.

Abstract

The need to control the sanitary situation has led governments to implementing several restrictions with substantial social and financial impacts. This paper aims to understand how people prioritize their income and social restrictions, as well as society’s level of education and poverty, relative to the immediate health effects of the pandemic, in Portugal. Specifically, we estimate the level of sacrifice that individuals are willing to make to reduce the Covid-19 death burden.

In the sample, with over 2,500 answers, the number of Covid-19 related deaths is the attribute with the largest negative effect on the respondents’ utility. Estimates suggest that individuals would be willing to sacrifice 20% of their income to save 47 lives per day during the first 6 months of 2021. For the same period, they would also accept 20% of school population to become educationally impaired to avoid 25 daily deaths; a strict lockdown to avoid 23 daily deaths; and 20% of the population to become poor to save 100 individuals, daily. 

Sub-group analysis helps demystify some general myths and opinions around some socioeconomic characteristics, showing that some generalizations discussed in the Portuguese media and public opinion do not find support in our data.

These findings suggest that there was support to the measures taken at that time, that included closing schools, a strict lockdown and reducing the economic activity, if these led to saving lives.

Abstract

Hospital strikes in the Portuguese National Health Service (NHS) are becoming increasingly frequent. This paper analyses the effect of different health professionals' strikes (physicians, nurses, and diagnostic and therapeutic technicians (DTT) - DTT) on patient outcomes and hospital activity. Patient-level data, comprising all NHS hospital admissions in mainland Portugal from 2012 to 2018, is used together with a comprehensive strike dataset with almost 130 protests. Data suggests that hospital operations are partially disrupted during strikes, with sharp reductions in surgical admissions (up to 54%) and a decline on both inpatient and outpatient care admissions. The model controls for hospital characteristics, time and regional fixed effects, and case-mix changes. Results suggest a modest increase in hospital mortality limited for patients admitted during physicians' strikes, and a slight reduction in mortality for patients already at the hospital when a strike takes place. Increases in readmission rates and length of stay are also found. Results suggest that hospitals and legal minimum staffing levels defined during strikes are not flexible enough to accommodate sudden disruptions in staffing, regardless of hospital quality in periods without strikes.

Abstract

Reference price regimes for prescription drugs are usually implemented with the aim of curbing public expenditure with pharmaceuticals, induce drug substitution from branded to generics drugs and enhance competition. In these systems, patients co-pay the difference between the drug’s pharmacy retail price and the reimbursement level. Relying on a detailed product-level panel dataset of prescription drugs sold in Portuguese retail pharmacies, from 2016 to 2019, we evaluate pharmaceutical firms pricing decisions for branded and generic drugs, as well as consumers' reaction to price changes. In particular, we exploit the variation induced by a policy change, which increased reference prices for 36% of the equivalent-drug groups in our sample.

Results of a difference-in-differences analysis show that, despite the reference price increase, affected firms also increase their prices - particularly for off-patent branded products. Such reaction from firms results in an increase in the price paid by patients. Such price effects resulted on a 16% decline on branded drugs consumption, with significant heterogeneity across regions and therapeutics. 

Estimates suggest that NHS co-payments savings were achieved through higher out-of-pocket payments paid by patients. Additionaly, pharmaceutical firms' reaction to the reference price increase was contrary to what was expected, suggesting underlying competitive dynamics which should be considered prior to policy changes.

Abstract

The COVID-19 pandemic led to necessary and similar responses internationally, including non-pharmaceutical interventions (NPI). Before the vaccine rollout, NPI were the main available tools to tackle the pandemic. These include physical distancing, frequent hand washing, use of face mask, respiratory hygiene and use of contact tracing apps. The main goal of this study was to describe the factors associated to COVID-19 NPI compliance.

We performed an online panel survey distributed between 28th October 2020 and 11th January 2021. Each of the self-reported NPI measures’ compliance was considered as the outcome. Sociodemographic, respondent concerns, agreement with the NPI measures, among other characteristics, were studied through logistic regressions.

We obtained a total of 1263 responses, with high levels of NPI compliance except for the contact tracing app. Those characteristics with highest compliance were female sex and age. There were differences in compliance across the different regions and a gradient between agreement and compliance.

Pandemic management and communication plans should be designed using results of such analyses and surveys. Policy measures to increase NPI compliance can be specifically tailored according to population characteristics.

Abstract

This paper aims to understand the role of sociodemographic conditions, political factors, organizational confidence, and non-pharmaceutical interventions compliance, as drivers of vaccine hesitancy in Brazil.

Using a nationwide online survey in Brazil, applied between November 25th, 2020 and January 11th, 2021, the paper performs descriptive analysis with main variables on non-pharmaceutical interventions and vaccine hesitancy. Moreover, it also uses logistic regression models to investigate the drivers of vaccine hesitancy.

Results suggest: 1) less concern with the vaccine side effects could improve the willingness to be vaccinated (probability changed by 7.7 pp and p<0.10); 2) current vaccine distrust from the Brazilian president, contributes to the vaccine hesitancy, among his voting base; 3) lower performance perception (“Very Bad” with 10.7 pp and p<0.01) or higher political opposition (left-oriented) of the current federal government influence the willingness to be vaccinated; and 4) higher compliance with the non-pharmaceutical interventions (NPIs) tend to be related with the agreement to take the Covid-19 vaccine (+1 score to the NPI compliance index could improve 1.4 pp, at p<0.05, to the willingness to the vaccine).

The willingness to be vaccinated is strongly influenced by the political positioning, federal government performance perception, vaccine´s side effects and compliance with non-pharmaceutical interventions (NPIs).

Abstract

Background: The COVID-19 pandemic has led to disruptive changes worldwide, with different implications across countries. The evolution of citizens’ concerns and behaviours overtime is a central piece to support public policies.

Objective: To unveil perceptions and behaviours of the Portuguese population regarding social and economic impacts of the COVID-19 pandemic, allowing for more informed public policies. 

Methods: Online panel survey distributed in three waves between March 13th and May 6th 2020. Data collected from a non-representative sample of 7,448 respondents includes socio-demographic characteristics and self-reported measures on levels of concern and behaviours related to COVID-19. We performed descriptive analysis and probit regressions to understand relationships between the different variables.

Results: Most participants (85%) report being at least very concerned with the consequences of the COVID-19 pandemic and social isolation reached a high level of adherence during the state of emergency. Around 36% of the sample anticipated consumption decisions, stockpiling ahead of the state of emergency declaration. Medical  appointments suffered severe consequences, being re-rescheduled or cancelled. We find important variation in concerns with the economic impact across activity sectors.

Conclusion: We show that high level of concern and behaviour adaptation in our sample preceded the implementation of lockdown measures in Portugal around mid-March. One month later, a large share of individuals had suffered disruption in their routine health care and negative impacts in their financial status.

Abstract

Health spending has been increasing over time across developed economies. Despite significant differences in terms of how health care is provided to the population, all countries have a significant share of public spending in total health spending. Coupled with fragile public finances and adverse macroeconomic environments, the quest for efficiency in the health sector remains one of the key challenges governments currently face.

This chapter discusses the main challenges on measuring efficiency of public health spending. The first section describes the main characteristics of the health sector and highlights the rationale behind public intervention in health. The second section provides an overview of the relevant literature and discusses methodological challenges on measuring efficiency in the health sector. The third section illustrates these challenges by providing a critical analysis of public health spending efficiency. Finally, the last section concludes.

Abstract

Abstract

The provision of universal healthcare by the Portuguese NHS depends on the allocated government budget to health. Several reforms have been implemented over the last decades to improve access while ensuring the financial sustainability of the healthcare system. However, a practical and usable definition of public health sustainability is hard to find. We show that under two alternative definitions – both related to fiscal space and compliance with sound public finances - public health spending increase is limited. Our analysis indicates that public health spending growth levels below 3% can be financially sustainable.

Taking into account that financial sustainability is a function of economic growth, and will depend on the level of control of other public spending,  our forecast for long-run health spending growth is compatible with the financial sustainability targets defined.

Abstract

In this chapter we provide an assessment of the efficiency of health systems, using an aggregate production function as a representation of the broad features and characteristics of health systems, to highlight the role of doctors and nurses. We find that inefficiencies, in the sense of resources’ waste, do not seem to be a result of different human resources policies, here captured as different nurses to doctor ratios. However, different ratios lead to different costs. Thus, using a constant elasticity of substitution production function, we estimate the excess cost faced by the health system associated with non-optimal nurses to doctor ratios.

Abstract

The Health Emergency Plan was presented in May 2024 by the Ministry of Health. This plan is a health policy instrument aimed at tackling urgent and priority challenges in access to healthcare in Portugal. Structured around five strategic axes, the plan proposes a comprehensive set of measures that respond to the current critical needs of the healthcare system. Each strategic axis was analysed by a group of health professionals, resulting in the preparation of Policy Briefs that summarise the main recommendations and directions for action. These documents also present a critical analysis of the measures implemented and propose possible improvements in their implementation.

Abstract

Realizado no âmbito de um protocolo assinado entre o PlanAPP e a ADSE, o estudo faz uma caracterização da população de beneficiários e analisa as fontes de financiamento e responsabilidades deste subsistema de saúde, avaliando ainda a sustentabilidade do sistema a partir de projeções da evolução da estrutura demográfica dos beneficiários da ADSE e das respetivas contribuições e despesas.

Abstract

The Short Notes series intends to provide analysis on key topics related with the health sector. This fifth short note explores the conceptual and methodological challenges associated with measuring unmet health care needs.  In 2019, around 40% of Portuguese people with health needs had at least one situation in which they were unable to access healthcare, a figure substantially higher than the European average of 26%, which puts Portugal in an unfavourable position compared to other European countries. The lack of access to healthcare in Portugal is mainly due to financial difficulties, with access to oral health and mental health care being particularly problematic.

Abstract

A saúde e as políticas públicas em saúde têm um potencial intergeracional que não é dispiciente, sendo necessário ponderar os efeitos de longo prazo das decisões associadas a essas políticas. As determinantes socio-económicas da saúde, o desenvolvimento económico e a partilha de recursos têm implicações na saúde das gerações futuras, merecendo por isso uma atenção específica. De facto, na área da saúde, os benefícios e contribuições para os investimentos em saúde são capturados de forma diferente ao longo da vida de cada indivíduo, mas também entre indivíduos de gerações diferentes. As potenciais discrepâncias entre as várias gerações motivam por isso a análise da evolução da justiça intergeracional da saúde e do cálculo de um índice de justiça intergeracional. 

Abstract

The Health Spending Observatory intends to provide regular analysis on the dynamics of health spending in Portugal. This includes the analysis of the State Budget, financial arrears, and financing sources of the health system, among others. This publication analyses health expenditure in community pharmacies in Portugal. The weight of direct household payments in community pharmacies rose from 39% in 2000 to 45% in 2020. This increase reflects the 'insignificant' weight of health insurance and health subsystems in health expenditure in community pharmacies and reveals the potential reduction in financial protection of the population. NHS expenditure accounted for around 49%. Between 2003 and 2022, the number of packages dispensed increased by 40%, signalling a progressive increase in demand for medicines. Over the analysed period, the increase in consumption contributed to a 37% increase in the cost of medicines. Conversely, the reduction in prices during this period contributed to a 16% reduction in costs. Thus, the combination of these two effects resulted in an increase in costs of 21%.

Abstract

The Health Spending Observatory intends to provide regular analysis on the dynamics of health spending in Portugal. This includes the analysis of the State Budget, financial arrears, and financing sources of the health system, among others. This report investigates the relevance of direct payments by households in the financing of the Portuguese health system. Approximately 29% of health spending is directly financed by Portuguese households at the moment of healthcare provision. Most direct payments are associated with the use of private outpatient care and the purchase of medicines in community pharmacies. Direct payments put greater pressure on lower income households and constitute a potential barrier to access. Attempts to improve healthcare access through a reduction in direct payments by households should mainly target the reimbursement of medicines and access to outpatient care, in particular oral health for economically deprived households.

Abstract

The Short Notes series intends to provide analysis on key topics related with the health sector. This fourth short note investigates the individual use of contact tracing apps in the context of the COVID-19 pandemic, based on data collected from an European survey since the beginning of the pandemic. Within the countries included in this study, Portugal displays the lowest rate of download and utilization of such apps during the pandemic. In this short note we discuss three potential channels that affect the success of these apps: the technological landscapes and apps’ features, the individual adherence of each citizen, and the ability to achieve a minimum scale to induce a network effect.

Abstract

Access to healthcare is among the main concerns of the population regarding health systems functioning and performance. The COVID-19 pandemic has disrupted health systems, with consequences in terms of access to healthcare as well. Based on an annual survey, this report displays the evolution of health care access in Portugal, with a particular focus on the years of 2020 to 2022. Together with past editions, it is possible to analyse key trends since 2013. This report details multiple dimensions of health care access, including disease incidence, the decision to look for health care, access barriers (financial and non-financial), and the public vs private health care provision.

Abstract

Human Resources in the Health Care sector are considered the backbone of Health Systems. The discussion regarding health systems’ challenges implies an analysis of the role that human resources have in the health system. This report presents a set of analysis on multiple challenges affecting health professionals in the Portuguese health system, particularly physicians and nurses. Multiple factors that may contribute to the difficulty on attracting and retaining professionals are discussed in the report. This includes analysis on health professionals ageing, income, dual practice, migration, training capabilities, among others. Additionally, a discussion on task-shifting and skill-mix is also included to discuss its implications in the Portuguese Health System.

Abstract

A série de Notas Informativas pretende divulgar análises curtas relativas a temáticas atuais sobre o setor da saúde. Com base em dados de um inquérito europeu recolhidos desde o início da pandemia, esta segunda nota analisa a evolução do apoio da opinião pública a medidas restritivas implementadas por vários governos no contexto da pandemia de COVID-19. Verificam-se diferenças significativas no apoio da opinião pública entre os sete países incluídos no inquérito. Os resultados sugerem que a perceção de risco influencia o apoio da opinião pública a medidas mais restritivas. Apesar disso, o apoio a medidas restritivas em Portugal tem estado em queda ao longo do tempo.

Abstract

The Short Notes series intends to provide analysis on key topics related with the health sector. This second short note investigates the evolution of public opinion support for restrictive measures implemented in the context of the COVID-19 pandemic, based on data collected from an European survey since the beginning of the pandemic. Noticeable differences in public opinion support are identified across the seven countries included in the survey. Data suggests that risk perception influences public opinion support for more restrictive measures. Nonetheless, the overall support for restrictive measures in Portugal has been declining over time.

Abstract

Abstract

The Health Spending Observatory intends to provide regular analysis on the dynamics of health spending in Portugal. This includes the analysis of the State Budget, financial arrears, and financing sources of the health system, among others. This report investigates the relation between private health insurance and the National Health Service (NHS). Despite the significant growth over the last decades, private health insurance represents only 4% of overall health spending. Moreover, the growth of private health systems seems independent from NHS expenditures: the growth of private insurance does not seem related with any crowding-out of public expenditures. Instead, a significant share of the growth of private health insurance is explained by a reduction of the health subsystems.

Abstract

The Health Spending Observatory intends to provide regular analysis on the dynamics of health spending in Portugal. This includes the analysis of the State Budget, financial arrears, and financing sources of the health system, among others. This policy brief investigates the forecasts of the 2023 State Budget for the Health sector. The Budget for 2023 increases the share of health spending in public expenditures to its highest value in the last decade. However, a significant part of such increase is related with price effects – a major increase in health care provision is not expected. The current forecasts for human resources expenditures and goods and services purchases may not be enough to meet existing needs. A reduction in capital expenditures relative to its budget may be used to finance budget overruns in human resources and goods and services expenditures.

Abstract

The Short Notes series intends to provide analysis on key topics related with the health sector. This first short note investigates the evolution of trust on government’s information, based on data collected from an European survey since the beginning of the pandemic. Noticeable differences in the trust level are identified across time and across the seven countries included in the survey. More recent data, relative to the beginning of this year, places Portugal as the country with the highest level of trust on government’s information. Moreover, differences can also be identified across age groups. 

Abstract

The Portuguese health system ensures the provision of healthcare to its population through a network of public hospitals and primary care centres, complemented by private healthcare providers and a long-term care network. Overall, when compared to other countries, the health care system seems to perform relatively well in terms both of quality delivered and financial indicators. 

However, significant challenges persist, particularly within the National Health Service. Still, several reforms have been implemented over the last decades to modernize the health system and contribute to its financial sustainability. In fact, Portugal has a relatively old and unhealthy population, leading to a high prevalence of chronic diseases and an increasing burden associated with ageing. It is expected that these effects will generate additional pressure in an already constrained health system. The modest economic growth recorded over the last years and the related financial constraints have limited the capacity of the health system to meet the increasing demand. Surgical waiting lists, excess demand for long-term care, and patients with unassigned GPs are some of the signs of a pressured health system. Some of these historical problems have been amplified by the Covid-19 pandemic which disrupted the provision of healthcare. 

This work provides a discussion on the main challenges faced by the Portuguese Health System and provides an analysis of the main opportunities that should be pursued. 

Abstract

The present paper revisits the topic of real wage cyclicality by characterizing the impact of the business cycle along the conditional real wage distribution. Using matched employeremployee data for Portugal, we provide what we believe is compelling microeconometric evidence showing, for the first time, that the sensitivity of real wages to the business cycle is much stronger for high-wage workers than for low-wage workers.

The issue of wage cyclicality has been a long-contested question (Abraham and Haltiwanger, 1995). While earlier evidence based on aggregate data showed conflicting results regarding the impact of the cycle on wages, studies that use individual-level longitudinal data generally conclude that real wages are procyclical, decreasing in recessions and rising during expansions (Bils, 1985; Solon et al., 1994; Carneiro et al., 2012). These studies also show that the sensitivity of wages to the cycle is stronger for job movers, a claim that has helped reconcile the canonical search and matching model with aggregate unemployment volatility (Pissarides, 2009) but has recently been disputed empirically by Gertler et al. (2020).

We use a rich matched employer-employee administrative dataset from Portugal covering the universe of private sector wage earners from 1986-2020 to estimate wage cyclicality parameters for the 10th, 50th and 90th percentiles of the hourly real wages distribution. We employ conditional quantile regressions (Koenker and Bassett Jr, 1978) and method of moments quantile regressions (Machado and Silva, 2019), the latter of which allow for the inclusion of high-dimensional fixed effects to control for composition effects stemming from worker, firm, and match unobserved, time-invariant heterogeneity.

According to our estimates, a one percentage point decrease in the unemployment rate leads to 0.7 percent wage increase for workers in the 10th percentile of the (conditional) wage distribution whereas it generates a 1.2 percent wage increase for workers in the 90th percentile. If we consider newly hired workers, the semi-elasticities are -1.1 for workers in the 10th percentile and -1.8 for workers in the 90th percentile. An important implication of this asymmetrical reaction is that economic expansions tend to exacerbate wage inequality whereas economic contractions tend to attenuate it.

To investigate the sources of real wage cyclicality we explore two new routes. Firstly, we investigate the cyclicality of minimum wages and of bargained wages. We provide empirical evidence supporting the notion that both real minimum wages and real bargained wages are pro-cyclical. Observed real hourly wage, nevertheless, still exhibit significant asymmetrical responses to changes in the unemployment rates after controlling for the influence of minimum wages and bargained wages in the formation of wages. Secondly, we account for compositional bias by including worker and firm fixed effects in the wage regression models. Here, we confirm that the employment losses of low wage workers during economic recession tend to downwardly bias the cyclicality of real wages. Be that as it may, the asymmetrical reaction on the part of high and low wage workers remains after the inclusion of minimum wages, bargained wages, and the worker and firm fixed effects in the wage equation.

Another novel feature of our empirical approach is that we compute a direct measure of the job match quality. This measure is constructed using a two-way high-dimensional regression model, where the job match fixed effect is decomposed into three components: the worker fixed-effect, the firm fixed effect, and the job match quality fixed effect. Critically,  we calculate the job match quality fixed effect assuming it to be orthogonal to the worker and firm fixed effects. A noteworthy result of this decomposition is that, once we account for job match quality, there is no longer a distinct wage reaction for job stayers and new hires, a result that vindicates the claim of Gertler et al. (2020).

Finally, we address the possibility of heterogenous wage responses to aggregate economic fluctuations. Firstly, after restricting the sample to larger and more perennial firms, we estimate firm-specific semi-elasticities and verify, with some surprise, that about one third of the firms exhibited a counter-cyclical behavior. The other two thirds displayed pro-cyclical responses to changes in the unemployment rate, driving the (negative) sign of aggregate semi-elasticity. Secondly, we consider the likelihood that real wages in distinct collective wage agreements, which largely identify different industries, may respond differently to business cycle fluctuations. Here, we uncover, again, widespread heterogeneity in the responses to the business cycle. Furthermore, we show that high-wage workers tend to sort themselves into more procyclical firms and collective agreements.

Our novel results harness the benefits of using a rich dataset to explore the full distribution of wages. We show how important it is to move beyond the linear model of Bils (1985), as different workers and firms show different reactions to the cycle. As such, we provide strong empirical evidence on the role of the business cycle as amplifier of inequality trends.

Abstract

Background: Health and social security systems’ goals are to deliver healthcare and social protection for the population. This study aims to explore the relationship between health and social expenditures in their role in affecting health outcomes, such as health-adjusted life expectancy (HALE), life expectancy (LE), death rates (DR) and disability-adjusted life years (DALYs).

Methods: We used a translog production function using both health and social expenditures as inputs, for a panel of 29 years and 36 OECD countries, to estimate their respective output elasticities and the elasticity of substitution between them. Instrumental variables and ridge regressions were used to estimate unbiased elasticities.

Results: Between 1990 and 2018 for these 36 countries, the elasticity of substitution between social and health expenditures was positive and higher than one, being thus considered substitutes. However, it is heterogeneous across countries, years, and health outcomes. It was found that for each raise of 1% investment in health, it is needed a raise between 2.22% and 21.5% raise in social services investment to achieve the same results in terms of health outcomes.

Conclusions: Our results imply a relevant substitution relation between health and social expenditure. Although the biggest impact is from health spending, investments in the social sector may also impact health and act as a partial substitute. Thus, policymakers need to acknowledge the joint effect of these two spending categories when considering investment decisions aiming at achieving specific health gains.

Abstract

This paper investigates competitive dynamics of pharmaceutical firms. In particular, we analyze how the presence in different markets and repeated interaction with rivals affect the competitive environment. Moreover, we explore the effects that generic entry in a new off-patent statin had on the generic prices in older off-patent statins.

We use the Portuguese statins market, where prices are capped, as a case-study to investigate such competitive dynamics. Since prices are capped, the distance between the drug price and the drug price cap becomes the key variable of interest in this paper. We combine information from two data sets. The first contains drug sales for pharmacies by product across regions. The second is a pricing database containing retail, reference, and price caps for all drugs sold in the Portuguese Reference Price System.

Results suggest that the presence in several markets does not lead companies to set lower prices, relative to their caps. Moreover, estimates show that companies rely on repeated interaction with rivals to soften price competition. Finally, the entry of a new molecule (rosuvastatin) impacts the competitive pressure imposed by generic competition only at the molecular level, as it does not spread to substitute off-patent molecules. Overall, price competition in these markets remains low, with price caps being the main determinant of drug prices.

Abstract

Managing time during exam seasons can be one of the most difficult tasks students face. The time constraint faced by students imply an implicit choice among multiple dimensions, including grades, sleep time, leisure time, study time and mental health status. This paper aims at quantifying the tradeoffs that college students face during the exam season, through a Discrete Choice Experiment, with a sample of Portuguese college students. According to the survey results, students place more importance on a higher GPA during the exam season, followed by lower depression levels, higher levels of leisure time, lower levels of daily study hours, and sleep hours. First and second year students are more likely to place higher valuation on GPA and lower valuation on mental health than third year students or higher. Policy makers must be mindful of the tradeoffs faced by students and their heterogeneity. They should consider how potential policy changes in the higher education system are expected to affect the weights of each dimension, influencing the choices made by different types of students.

Abstract

In most OECD countries, health spending has been increasing over the last decades, often surpassing GDP growth. Current challenges faced by health systems - including the Covid-19 pandemic - pose additional concerns regarding whether societies can sustain continuous health spending growth. Such problem is particularly relevant in the context of public health spending. In the absence of significant economic growth, the room for further increases in public health spending without constraining other public spending is somewhat limited.

On this paper I propose an exploratory analysis on the concept of financial sustainability of public health spending. I relate the sustainability concept with fiscal space of public finances and with the crowding-out of other public expenditures. I develop a static model where health contributes directly both to utility and output.

The model suggests that increases on public health spending are not necessarily undesirable from a public finances' standpoint: the crowding-out of non-health public expenditures depends on the tax rate and coverage level of public health spending. Thus, economic growth is not a sufficient condition to achieve financial sustainability of health spending. Moreover, achieving financial sustainability by adjusting coverage levels might compromise ensuring the social sustainability of public health spending. Hence, this paper contributes to the debate on whether current increases of public health spending are desirable and sustainable.