Guilhermina Rego

The challenge of corporatisation: the experience of Portuguese public hospitals

The inability of traditional state organisations to respond to new economic, technological and social challenges and the associated emerging problems has made it necessary to adopt new methods of health management. As a result, new directions have emerged in the reform of Public Administration together with the introduction of innovative models. The aim is to achieve a type of management that focusses on results as well as on effort and efficiency. We intend to analyse to what extent the adoption of business management models by hospital healthcare units can improve their performance, mainly in terms of standards of efficiency. Data envelopment analysis (DEA) was used to investigate the efficiency of a set of public Portuguese hospitals. The aim was to evaluate the impact of business management in Portuguese public hospitals with regards to efficiency, specifically taking into account the fact that lack of resources and increased health care needs are a present and future reality. From a total of 83 public hospitals, a sample of 59 hospitals was chosen, of which 21 are state-owned hospital enterprises (SA) and 38 are traditional public administration sector hospitals (SPA). This study evaluates hospital performance by calculating two efficiency measures associated with two categories of inputs. The first efficiency measures the costs associated with hospital production lines and the number of beds (representing fixed capacity) as inputs. The annual costs generated by the hospitals in the consumption of capital and work (direct and indirect costs) are used. A second measure of efficiency is calculated separately. This measure includes in the inputs the number of beds as well as the human resources available (number of doctors, number of nurses and other personnel) in each hospital. With regard to output, the variables that best reflect the hospital services rendered were considered: number of inpatient days, patients discharged, outpatient visits, emergencies services, sessions in hospital day care services and the number of surgeries. The results seem to suggest that the introduction of market processes and changes in organisational structure—such as managerial autonomy and corporatisation of public hospitals—have had a positive impact on Portuguese public hospitals. This positive evolution was particularly evident in SA hospitals, but further studies are needed to confirm these preliminary results.

Social Responsibility: A New Paradigm of Hospital Governance?

Changes in modern societies originate the perception that ethical behaviour is essential in organization’s practices especially in the way they deal with aspects such as human rights. These issues are usually under the umbrella of the concept of social responsibility. Recently the Report of the International Bioethics Committee of UNESCO on Social Responsibility and Health has addressed this concept of social responsibility in the context of health care delivery suggesting a new paradigm in hospital governance. The objective of this paper is to address the issue of corporate social responsibility in health care, namely in the hospital setting, emphasising the special governance arrangements of such complex organisations and to evaluate if new models of hospital management (entrepreneurism) will need robust mechanisms of corporate governance to fulfil its social responsiveness. The scope of this responsible behaviour requires hospitals to fulfil its social and market objectives, in accordance to the law and general ethical standards. Social responsibility includes aspects like abstention of harm to the environment or the protection of the interests of all the stakeholders enrolled in the deliverance of health care. In conclusion, adequate corporate governance and corporate strategy are the gold standard of social responsibility. In a competitive market hospital governance will be optimised if the organization culture is reframed to meet stakeholders’ demands for unequivocal assurances on ethical behaviour. Health care organizations should abide to this new governance approach that is to create organisation value through performance, conformance and responsibility.

Alzheimer, dementia and the living will: a proposal

The world population aged significantly over the twentieth century, leading to an increase in the number of individuals presenting progressive, incapacitating, incurable chronic-degenerative diseases. Advances in medicine to prolong life prompted the establishment of instruments to ensure their self-determination, namely the living will, which allows for an informed person to refuse a type of treatment considered unacceptable according to their set of values. From the knowledge on the progression of Alzheimer disease, it is possible to plan the medical care, even though there is still no treatment available. Irreversible cognitive incapacity underlines the unrelenting loss of autonomy of the demented individual. Such a loss requires the provision of specific and permanent care. Major ethical issues are at stake in the physician–patient–family relationship, even when dementia is still at an early stage. The authors suggest that for an adequate health care planning in Alzheimer disease the living will can be presented to the patient in the early days of their geriatric care, as soon as the clinical, metabolic or even genetic diagnosis is accomplished. They also suggest that the appointment of a health care proxy should be done when the person is still in full enjoyment of his cognitive ability, and that the existence and scope of advance directives should be conveyed to any patient in the early stages of the disease. It follows that ethical guidelines should exist so that neurologists as well as other physicians that deal with these patients should discuss these issues as soon as possible after a diagnosis is reached.

Public Accountability and Sunshine Healthcare Regulation

The lack of economic sustainability of most healthcare systems and a higher demand for quality and safety has contributed to the development of regulation as a decisive factor for modernisation, innovation and competitiveness in the health sector. The aim of this paper is to determine the importance of the principle of public accountability in healthcare regulation, stressing the fact that sunshine regulation—as a direct and transparent control over health activities—is vital for an effective regulatory activity, for an appropriate supervision of the different agents, to avoid quality shading problems and for healthy competition in this sector. Methodologically, the authors depart from Kieran Walshe’s regulatory theory that foresees healthcare regulation as an instrument of performance improvement and they articulate this theory with the different regulatory strategies. The authors conclude that sunshine regulation takes on a special relevance as, by promoting publicity of the performance indicators, it contributes directly and indirectly to an overall improvement of the healthcare services, namely in countries were citizens are more critical with regard to the overall performance of the system. Indeed, sunshine regulation contributes to the achievement of high levels of transparency, which are fundamental to overcoming some of the market failures that are inevitable in the transformation of a vertical and integrated public system into a decentralised network where entrepreneurialism appears to be the predominant culture.

Abortion among adolescents: a bioethical approach

OBJECTIVES: to describe the socio-demographic, behavioral, clinical and anatomical-pathological characteristics and the type of abortion in adolescents as a way of discussing the subject from a bio-ethical perspective. METHODS: a structured questionnaire was applied to 201 adolescent girls receiving treatment for incomplete abortion and being subjected to uterine curretage, at a public maternity unit in the Northeast region of Brazil. RESULTS: the mean age was 16.1 years; most girls had a stable partner, were of mixed race, and were not accustomed to using condoms during sexual intercourse. The mean age for initiation of sexual activity was 15 years. Most had not planned the pregnancy but wanted to get pregnant. The mean gestational age of the fetus was 13.2 weeks. With regard to the type of abortion, 1.99% were spontaneous and 81.59% were certainly provoked, according to data obtained using the World Health Organization classification. Fetal and maternal tissue were 88.56% and 11.44%, respectively. Of the abortions that were certainly provoked, there was one case of the use of a hydatidiform mole. CONCLUSIONS: it is recommended that strategic family planning programs be urgently introduced and that anatomical-pathological tests be carried out on the material resulting from an abortion. Proactive bioethical reflection seems to be the tool for providing minimal guidelines for the protection and care of adolescents and for assisting health professionals.

Healthcare regulation as a tool for public accountability

The increasing costs of healthcare delivery led to different political and administrative approaches trying to preserve the core values of the welfare state. This approach has well documented weaknesses namely with regard to healthcare rationing. The objective of this paper is to evaluate if independent healthcare regulation is an important tool with regard to the construction of fair processes for setting limits to healthcare. Methodologically the authors depart from Norman Daniels’ and James Sabin’s theory of accountability for reasonableness and try to determine if new regulatory models—namely independent agencies—perform better with regard to the public disclosure of the reasons and rationales of healthcare rationing. In publicly financed healthcare systems independent regulation is an important tool to assure fair and reasonable procedures of prioritising services. In accordance with the principle of public accountability, independent regulatory agencies are particularly well suited to assure publicity of the decision-making processes, relevance of the rationale involved and particularly mechanisms for challenge and dispute resolution regarding limit setting decisions. It follows that independent healthcare regulation could be regarded not only as an instrument for performance improvement but also as a tool of social justice. The authors conclude by stating that accountability for reasonableness should be regarded as a landmark of any healthcare reform. And therefore regulators have the social task of assuring that the rationales for limit-setting decisions are clearly accessible to the public.

The rise of independent regulation in health care.

In all countries where health care access is considered a social right, regulation is both a tool of performance improvement as well as an instrument of social justice. Both social (equity in access) and economical (promoting competition) regulation are at stake due to the nature of the good itself. Different modalities of regulation do exist and usually new regulatory cycles include the creation of stronger regulatory agencies. Indeed, health care regulation is rising steadily in most developed countries as a consequence of the introduction of the New Public Management perspective to provide essential public goods.Health care is delivered by different organisations with very different cultural backgrounds—public and private (profit and non-profit)—that should be accountable for their decisions. Control by regulatory agencies is instrumental to accomplish this goal. However, there is some dispute with regards the degree of regulatory autonomy. The objective of this paper is to determine if independent regulatory agencies (IRAs) are effective in carrying out health care regulation. The authors apply Walshe’s analytical framework to the Regulatory Authority of Health (Portugal) to answer the question if independent regulation works.In conclusion, the two year experience of the Regulatory Authority of Health is important not only because the primary goals of independent regulation were achieved but also because this authority is now a full partner in the health care sector. However, independent agencies need to develop strong mechanisms of accountability because good regulatory governance is the paradigm of this institutional innovation.

Health-related quality of life in children and adolescents with cochlear implants: self and proxy reports

Abstract Conclusions: Cochlear implantation appears to favour the perception of improved quality of life (QoL) among children and adolescents. Similar trends were observed among the responses of deaf children and their parents. However, parents of deaf children perceive fewer feelings of provocation than children and adolescents. Objective: This study aimed to assess health-related QoL (HRQoL) among prelingual profoundly deaf children and adolescents with cochlear implants and to compare the responses of these children to those of their parents. Methods: Our sample consisted of deaf children and adolescents with cochlear implants and two control groups: hearing children and adolescents and deaf children and adolescents. The ages of the participants ranged between 8 and 18 years. Parents and children/adolescents were surveyed using the Kidscreen-52, which is a generic instrument for assessing the HRQoL of children and adolescents. Structured interviews were conducted with parents to collect information and clinical histories, and the Graffar scale was used to assess socioeconomic status. Results: The hearing participants exhibited significantly higher QoL than the deaf participants without implants in nearly all domains. In contrast, although hearing participants exhibited a slightly higher QoL than implanted deaf children, these differences were smaller and failed to reach statistical significance.

Awareness of costs and individual accountability in health care

Questions of social justice and health-care costs are some of the concerns of society. The cost caused by cardiovascular diseases can have an enormous impact, and it is important to know what patients think about illness costs when they are hospitalized. Two interviews were realized in a longitudinal study, in a sample of 106 patients submitted to expensive techniques in Cardiology (Portugal), to understand the patients’ perception about the health costs and behavior changes based on awareness. We can conclude that cardiovascular diseases are a global phenomenon that generally affects all social groups. From those interviewed, 83% of the patients agree about getting information concerning the treatments and intervention costs during hospitalization because the information about costs can bring the necessary tools for improvement in patients and health resources; 70.8% of the patients say that this information could bring awareness to the patient’s life, enhancing responsibility and personal autonomy.

A interrupção da gravidez na adolescência: aspectos epidemiológicos numa maternidade pública no nordeste do Brasil

O abortamento provocado e praticado amplamente pelas mulheres, em contexto clandestino, no Brasil, sendo considerado uma questao de saude publica. Neste estudo, propoe-se a conhecer aspectos socio-demograficos, comportamentais, clinicos, complicacoes, e o tipo de abortamento praticado por adolescentes submetidas a curetagem uterina. Foi utilizada metodologia descritiva, atraves de entrevistas por meio de questionario estruturado no atendimento a 201 adolescentes com abortamento incompleto submetidas a curetagem uterina, em um hospital do Sistema Unico de Saude (SUS), em Maceio, Alagoas. Os principais determinantes para o abortamento foram: idade acima de dezesseis anos, com parceiro estavel; pardas; nao planejaram a gestacao; desejavam a gestacao, primigestas; idade gestacional menor que 15 semanas; raras complicacoes relacionadas ao abortamento, e utilizando a classificacao da Organizacao Mundial da Saude, observou-se abortamento provocado em 98,01% dos casos. Entre os casos de abortamentos certamente provocados, 89,19% reportaram o uso do misoprostol, o que reforca maior investimento publico na assistencia ao uso de metodos contraceptivos entre os adolescentes respeitando seus direitos sexuais e reprodutivos.