Decentralization and privatization in Portuguese health reforms

ABSTRACT - The Portuguese National Health Service (SNS), a universal, centralized and public owned health care system, exhibits an extraordinary record of equalization in the access to health care and health gains in the late thirty years. However, the most recent history of the Portuguese health reform is pervaded by the influence of decentralization and privatization. Decentralization has been present in the system design since the 1976 Constitution, at least in theory. Private ownership of health care suppliers and out-ofpocket expenditures, on the financing side, both have a long tradition of relevance in the NHS mix of services. The initial aim of this study was to demonstrate expected parallelism between health reforms and public administration reforms, where a common pattern of joint decentralization and privatization was observed in many countries. Observers would be tempted to consider these two movements as common signs of new public management (NPM) developments. They have common objectives, are established around the core concepts of gains in effectiveness, efficiency, equity and quality of public services, through improved accountability. However, in practice, in Portugal, each movement was developed in a totally separated way. Besides those rooted in the NPM theory, there are few visible signs of association between decentralization and privatization. Decentralization, in the Portuguese SNS, was never intended to be followed by a privatization movement; it was seen merely as a public administration tool. Private management of health services, as stated in the most recent SNS legislation, was never intended to have decentralization as a condition or as a consequence. Paradoxically, in the Portuguese context, it has led invariably to centralized control. While presented as separate instruments for a common purpose, the association between decentralization and privatization still lacks a convincing demonstration. Many common health care management stereotypes remain to be checked out if we want to look for eventual associations between these two organizational tools.

O financiamento hospitalar e a definição de preços

RESUMO - Inseridos num contexto onde as unidades prestadoras de cuidados de saúde não possuem autonomia para fixar os seus próprios preços, estuda-se através do presente documento o processo de definição de preços do internamento hospitalar português entre 1993 e 2001, no sentido de aferir o grau de sinalização proporcionado ao mercado, uma vez que, na sua essência, um sistema de preços constitui um sistema de incentivos influenciador de comportamentos produtivos ao nível prestador. Utilizou-se a base de dados nacionais do sistema de classificação de doentes Grupos de Diagnóstico Homogéneos e foi caracterizada a evolução e tendência dos pesos relativos dos produtos do internamento hospitalar português. Foi também avaliada a relação da estrutura de preços com a quantidade produzida, a eficiência técnica e as necessidades em saúde da população portuguesa durante o período considerado. Apesar de existir alguma instabilidade durante o período analisado, o ponto de partida e de chegada não diferiu significativamente. Não foi encontrado nenhum padrão de variação que explicasse a instabilidade encontrada entre os produtos mais complexos, mais produzidos ou os que apresentaram maior/menor variação ao longo da década de 90. A hipótese relativa à correlação entre a evolução de preços e as variáveis quantidade, eficiência e necessidades também foi infirmada. Conclui-se que a utilização do sistema de preços constituiu na sua essência um sistema de incentivos neutro, não foi sinalizador para os prestadores e possuiu uma forte correlação com o nível de reposição de custos históricos dos hospitais portugueses.

Continuidade e mudança. O sistema internacional no post‐Guerra Fria

O fim da Guerra Fria é um caso inédito de mudança pacífica da estrutura internacional, em que os Estados Unidos e a União Soviética transcendem a divisão bipolar para decidir os termos da paz no quadro das instituições que definem o modelo de ordenamento multilateral, consolidando a sua legitimidade. Nesse contexto, ao contrário dos casos precedentes de reconstrução internacional no fim de uma guerra hegemónica, o novo sistema do post-Guerra Fria, caracterizado pela unipolaridade, pela regionalização e pela homogeneização, forma-se num quadro de continuidade institucional. A ordem política do post-Guerra Fria é um sistema misto em que as tensões entre a hierarquia unipolar e a anarquia multipolar, a integração global e a fragmentação regional e a homogeneidade e a heterogeneidade política, ideológica e cultural condicionam as estratégias das potências. As crises internacionais vão pôr à prova a estabilidade da nova ordem e a sua capacidade para garantir mudanças pacíficas. A primeira década do post-Guerra Fria mostra a preponderância dos Estados Unidos e a sua confiança crescente, patente nas Guerras do Golfo Pérsico e dos Balcãs, bem como na crise dos Estreitos da Formosa. A reacção aos atentados do "11 de Setembro" revela uma tentação imperial da potência unipolar, nomeadamente com a invasão do Iraque, que provoca uma crise profunda da comunidade de segurança ocidental. A vulnerabilidade do centro da ordem internacional é confirmada pela crise constitucional europeia e pela crise financeira global. Essas crises não alteram a estrutura de poder mas aceleram a erosão da ordem multilateral e criam um novo quadro de possibilidades para a evolução internacional, que inclui uma escalada dos conflitos num quadro de multipolaridade regional, uma nova polarização entre as potências democráticas conservadoras e uma coligação revisionista autoritária, bem como a restauração de um concerto entre as principais potências internacionais.

Code name

The present case-study concerns about the analysis of the sale of Banif Mais, the sub-holding of Banif Group for specialized credit activity, taking into account the bank’s financial situation in 2014. In 2011, Portugal was submitted to an external finance programme carried out by troika which imposed very restricted measures to the financial sector. Subsequently, Banif was not able to accomplish the required results having to appeal to Government financing, being under a recapitalization plan since 2012.

On project finance and the first road concession in Portugal

In broad sense, Project Financing1 as a mean of financing large scale infrastructural projects worldwide has had a steady growth in popularity for the last 20 years. This growth has been relatively unscathed from most economic cycles. However in the wake of the 2007 systemic Financial Crisis, Project Financing was also in trouble. The liquidity freeze and credit crunch that ensued affected all parties involved. Traditional Lenders, of this type of financial instrument, locked-in long-term contractual obligations, were severely hit with scarcity of funding compounded by rapidly increasing cost of funding. All the while, Banks were “rescued” by the concerted actions of Central Banks and other Multi-Lateral Agencies around the world but at the same time “stressed” by upcoming regulatory effort (Basel Committee). This impact resulted in specific changes to this type of long-term financing. Changes such as Commercial Banks’ increased risk aversion; pricing increase and maturities decrease of credit facilities; enforcement of Market Disruption Event clauses; partial responsibility for project risk by Multilateral Agencies; and adoption of utility-like availability payments in other industrial sectors such as transportation and even social infrastructure. To the extent possible, this report is then divided in three parts. First, it begins with a more instructional part, touching academic literature (theory) and giving the Banks perspective (practice), but mostly as an overview of Project Finance for awareness’ sake. The renowned Harvard Business School professor – Benjamin Esty, states2 that Project Finance is a “relatively unexplored territory for both empirical and theoretical research” which means that academic research efforts are lagging the practice of Project Finance. Second, the report presents a practical case regarding the first Road Concession in Portugal in 1998 ending with the lessons learned 10 years after Financial Close. Lastly, the report concludes with the analysis of the current trends and changes to the industry post Financial Crisis of the late 2000’s. To achieve this I’ll reference relevant papers, books on the subject, online articles and my own experience in the Project Finance Department at a major Portuguese Investment Bank. Regarding the latter, with the signing of a confidentiality agreement, I’m duly omitting sensitive and proprietary bank information.

Crowdfunding

Crowdfunding, as we know it today, is a very recent activity that was born almost accidentally in the end of the 90’s decade. Due to the advent of the internet and the social networks, entrepreneurs are now able to promote their projects to a very large community. Whether it is composed by family, friends, acquaintances or simply people that are interested in the same topic or share the passion, the community is able to fund new ventures by individually investing modest amounts of money. In return, the entrepreneur can offer symbolic rewards, shares or other financial returns. New crowdfunding platforms are born almost every day all over the world, offering a new way of raising capital for their projects or a new way to invest their money in innovative ventures. Although crowdfunding is still finding its place in the financial services, successful cases such as Kickstarter demonstrate the power of the crowd in boosting creativity and productivity, financing thousands of projects by raising millions of dollars from thousands of investors. Due to regulatory restrictions, the most prominent model for now is reward-based crowdfunding, where the investors are prized with symbolic returns or privileged access to the products or services offered by the entrepreneurs. Other models such as peer-to-peer lending are also surging, allowing borrowers access to capital at a lower cost compared to so-called traditional financial institutions, and offering lenders a higher rate of return. But when it comes to offering shares to investors, i.e. using equity-based crowdfunding, entrepreneurs face regulatory obstacles in almost every country, where legislation was passed decades ago with the objective of promoting financially-capable ventures and protecting investors. Access to capital has become more difficult after the global economic recession of 2008, and for most countries it will not get easier in the near future, leaving start-ups and small enterprises with few options to start or expand their operations. In this study we attempt to answer the following research questions: how has equity-based crowdfunding evolved since its creation? Where and how has equity-based crowdfunding been implemented so far? What are the constraints and opportunities for implementing equity-crowdfunding in the world, and more particularly in Portugal? Finally, we will discuss the risks of crowdfunding and reflect on the future of this industry.

Vyndaqel (Tafamidis)

The main objective of this pedagogical case study is to analyse the market entry dynamics of pharmaceutical innovative drugs in Portugal, and the role and impact of the different stakeholders in this process. The case focuses on the market entry of Vyndaqel (Tafamidis) Pfizer’s orphan innovative product to treat TTR-FAP, “paramiloidose”, a highly incapacitating rare disease that has more than 2.000 diagnosed patients in Portugal, one of the highest prevalence worldwide and an incidence of 100 new patients every year. In terms of methodology it were used two main sources of information. Regarding secondary data sources it was made an exhaustive search using the main specialty search engines regarding the Tafamidis case, market access, orphan drugs and market entry context in Portugal and Europe. In terms of primary data it were conducted 7 direct interviews with the main case stakeholders. The pedagogical case study focuses on 5 main questions that provide the base of the discussion for the classes. First it is analysed the rationale behind the introduction of Tafamidis in Portugal, and its relevance for Pfizer, namely due to the previous investment made with the acquisition of FoldRX by $400M, the company that developed the product in the first place. It is also analysed the point of view of the NHS, and the reasoning behind drug reimbursement that considered not only the technical (efficacy and safety) and financial benefits of the drug, but also the social impact, due to the major role played by patient associations’ actions and coverage provided by the media that impacted the reimbursement decision. Finally it is analysed the vertical financing methodology that was selected by the Ministry of Health for drug acquisition by 2 public hospitals, that served as reference centres for the treatment of this disease