Quem manda?

— Quem manda? É a Troika, é a Troika, é a Troika!

O Copy/Paste das recomendações da Troika para a saúde, que segue em baixo, demonstra, sem qualquer margem para dúvidas, quem manda em Portugal. As recomendações são tão detalhadas e precisas que no Ministério da Saúde não devem ter tempo nem para respirar.
É caso para nos interrogarmos sobre como foi possível chegarmos a este ponto.



Health care system
Objectives
Improve efficiency and effectiveness in the health care system, inducing a more rational use
of services and control of expenditures;  generate additional savings in the area of
pharmaceuticals to reduce the overall public spending on pharmaceutical to 1.25 percent of
GDP by end 2012 and to about 1 per cent of GDP in 2013; generate additional savings in
hospital operating costs and devise a strategy to eliminate arrears.
The government will take the following measures to reform the health system: 
Financing 
3.41. The revision of NHS moderating fees (taxas moderadoras) will result in additional
revenues of EUR 150 million in 2012 and an additional 50 million in 2013. [Q4-2012]
3.42. In the light of the urgency and size of the savings needed in the health sector to
address large arrears and budget limitations, plans to achieve a self-sustainable model for
health-benefits schemes for civil servants will be accelerated. The current plan foresees that
the overall budgetary cost of existing schemes - ADSE, ADM (Armed Forces) and SAD
(Police Services) - will be reduced by 30 per cent in 2012 and by further 20 per cent in 2013  93
at all levels of general government. The system would become self-financed by 2016. The
costs of these schemes for the public budget  will be reduced by lowering the employer’s
contribution rate to 1.25% in 2013 and by adjusting the scope of health benefits. [Q3-2012].
Pricing and reimbursement of pharmaceuticals
3.43. Enact legislation which automatically reduces the prices of medicines when their
patent expires to 50 per cent of their previous price. [Q4-2012]
3.44. The government implements an annual revision of prices of medicines and of
countries of reference in order to achieve cost savings. Second price revision to be published
in January 2013.
3.45. The government will monitor monthly pharmaceutical expenditures and ensure that
the overall public pharmaceutical expenditure does not exceed the target of 1.25 per cent of
GDP in 2012 and 1 per cent of GDP in 2013. [Ongoing]
Prescription and monitoring of prescription 
3.46. Continue to improve the monitoring and assessment system of doctors' prescription
behaviour regarding medicines and diagnostic  in terms of volume and value and vis-à-vis
prescription guidelines and peers. Feedback continues to be provided to each physician on a
regular basis (e.g. quarterly), in particular  on prescription of costliest and most used
medicines. [Ongoing]
3.47. Continue to devise and enforce a system of sanctions and penalties, as a complement
to the assessment framework [Ongoing]. Assess the possibility of establishing agreements
with private sector physicians for the application of prescription rules as applied in the NHS.
3.48. Strictly monitor the implementation of the legislation making it compulsory for
physicians at all levels of the system, both public and private, to prescribe by International
Non-proprietary Name (INN) to increase the use of generic medicines and the less costly
available product. An implementation report will be published by December 2012.
3.49. Continue to publish prescription guidelines with reference to medicines and the
realisation of complementary diagnostic exams on the basis of international prescription
guidelines, audit their implementation and integrate them in the electronic prescription
system. A first set of guidelines is introduced in the e-prescription system by Q2 2013.
3.50. The government will produce a report assessing the effectiveness of the enacted
legislation aimed at removing all effective entry barriers for generic medicines, in particular
by reducing administrative/legal hurdles in order to speed up the use and reimbursement of
generics. [Q1-2013]
3.51. The above measures should aim at gradually and substantially increasing the share of
generic medicines to at least 30 per cent of all outpatient prescription (in volume) in 2012.
Targets for substantial further increases in 2013 will be agreed in the sixth review.
Pharmaceutical retailers and wholesalers
3.52. The Government will produce an intermediate assessment of the savings related to
the revision of the calculation of profit margins for wholesale companies and pharmacies.
[Q3-2012].
3.53. If the revision does not produce the expected reduction in the distribution profits of at
least EUR 50 million, an additional contribution in the form of an average rebate (pay-back)
will be introduced, which will be calculated on the mark-up. The rebate will reduce the new
mark-up on producer prices further by at least 2 percentage points on pharmacies and  94
4 percentage points on wholesalers. The rebate will be collected by the government on a
monthly basis through the Centro de Conferência de Facturas, preserving the profitability of
small pharmacies in remote areas with low turnover. [Q4-2013]
Centralised purchasing and procurement
3.54. Reinforce the centralised acquisition of vehicles, utilities, external services and other
cross functional goods and services by all entities included in the NHS, in order to reduce
costs through price volume agreements and fighting waste. A detailed  action plan will be
published by November 2012.
3.55. INFARMED will continue implementing the uniform coding system and a common
registry for medical supplies. [Ongoing]
3.56. Take further measures to increase competition among private providers and reduce by
an additional 10 percent the overall spending of the NHS with private providers delivering
diagnostic and therapeutic services (with particular reference to dialysis and rehabilitation).
Regularly evaluate and if necessary revise (at least every two years) the remuneration paid to
private providers with the aim of reducing the cost of more mature diagnostic and therapeutic
services. [Q4-2012]
3.57. Implement the centralised purchasing of medical goods through the recently created
Central Purchasing Authority (SPMS), using the uniform coding system for medical supplies
and pharmaceuticals. Assess the possibility of implementing the compulsory use of a
formulary in all hospitals to monitor the stock and flows of hospital medicines and medical
supplies and monitor compliance with central purchasing. [Ongoing]
3.58. Conduct an analysis of the market characteristics of relevant areas of service
provision such as dialysis and the pharmacies sector in view of ensuring competition and fair
prices in private markets.  [Q4-2013]
Primary care services
3.59. As part of the reorganisation of health services provision and notably the
concentration and specialisation of hospital services and the further development of a costeffective primary care service, the Government reinforces measures aimed at further reducing
unnecessary visits to specialists and emergencies and improving care coordination.
[Ongoing] This will be done through:
i. increasing the number of USF (Unidades de Saúde Familiares) units
contracting with regional authorities (ARSs) using a mix of salary and
performance-related payments as currently the case. Extend performance
assessment to the other primary care units (UCSPs). Make sure that the new
system leads to a reduction in costs and more effective provision;
ii. setting-up a mechanism to guarantee the presence of family doctors in needed
areas to induce a more even distribution of family doctors across the country;
iii. moving human resources from hospital settings to primary care settings and
reconsidering the role of nurses and other specialties in the provision of
services;
iv. updating patients' registration lists and the national register in order to increase
by at least 20 per cent the maximum number of patients per primary
care/family doctor for health centres and by 10 per cent for the USF.   95
Hospital services
3.60. Implement the strategy to clear arrears in the health sector, within the overall strategy
for settling and avoiding the re-emergence of arrears. Ensure standardised and tight control
procedures for all health sector entities to ensure expenditure commitments stay within the
budget allocated to each entity and therefore prevent the re-emergence of arrears. [Q3-2012]
3.61. Hospital SOEs will change the existing accounting framework and adopt accounting
standards in line with the requirements for private companies and other SOEs. This will help
improving the management of the enterprises and the quality of the financial oversight by the
general government. [Q4-2013]
3.62. Implement measures aimed at achieving a reduction of at least EUR 200 million in
the operational costs of hospitals in 2012. This is to be achieved through the reduction in the
number of management staff, concentration and rationalisation in state hospitals and health
centres with a view to reducing capacity. [Q4-2012]
3.63. Continue the publication of clinical guidelines and set in place an auditing system of
their implementation. [Ongoing]
3.64. On the basis of the comprehensive set of indicators, produce regular annual reports
comparing hospital performance (benchmarking). Establish a web-portal with publicly
available information. The first report is to be published by end 2012 and its results should
be used to establish targets for less performing hospitals. [Q4-2012]
3.65. Continue work to ensure full interoperability of IT systems in hospitals, in order for
the ACSS to gather real time information on hospital accounting and activities and to produce
monthly reports to the Ministry of Health and the Ministry of Finance. [Ongoing]
3.66. Continue with the reorganisation and rationalisation of the hospital network through
specialisation, concentration and downsizing of hospital services, joint management (building
on the Decree-Law 30/2011) and joint operation of hospitals. The aim is to adjust hospital
provision within the same health region, notably in the presence of newly established PPP
hospitals, adjust the activity of some hospitals from curative care towards areas such as
rehabilitation, long-term and palliative care and revise emergency and transplantation
structures. These improvements aim at eliminating unnecessary duplication, achieving
economies of scale and deliver additional cuts in operating costs by at least 5 percent in 2013
while improving the quality of care provided. A detailed action plan is published  by 30
November 2012 and its implementation is finalised  by end-2013. Overall, from  2011 to
2013, hospital operational costs must be reduced by at least 15 per cent compared to 2010
level. [Q4-2012]
3.67. Annually update the inventory of all health staff and prepare regular annual reports
presenting plans for the allocation of human resources in the period up to 2014. The report
specifies plans to reallocate qualified and support staff within the NHS. [Q2-2013]
3.68. Update the current legal framework applying to the organisation of working time of
healthcare staff, including introduction of rules to increase mobility within and across Health
Regions, adoption of flexible  time arrangements and review of payment mechanisms for
emergency work, the prevention regime and per call payments, notably by aligning overtime
remuneration in the health care sector with the general legal framework recently adopted. In
this context, overtime compensation should be reduced by 20% in 2012 and another 20% in
2013.[Q4-2012] 96
Regional health authorities
3.69. Improve monitoring, internal control and  fiscal risks management systems of the
Administrações Regionais de Saúde. [Q4-2012]
Cross services
3.70. Roll-out the system of patient electronic medical records and ensure access to all
relevant health care facilities. [Ongoing]
3.71. Reduce costs for patient transportation by one third compared to 2010. [Q4-2012]