I OVERVIEW

In Portugal, there is a fundamental right to health protection specifically set forth in the Chapter dedicated to fundamental rights in the Constitution of the Portuguese Republic. The right to health protection must be guaranteed: (1) by means of a universal and general national health service, which, with particular regard to the economic and social conditions of the citizens who use it, will tend to be free of charge; and (2) by creating economic, social, cultural and environmental conditions that particularly guarantee the protection of children, the young and the elderly; systematically improving living and working conditions, and promoting physical fitness and sport at schools and among the general population; and developing the public's health and hygiene education and healthy living practices.2

Healthcare services in Portugal are provided through three coexisting and overlapping systems: (1) the National Health Service (SNS), (2) special health insurance schemes for certain professions (health subsystems) and (3) voluntary private health insurance.

The SNS was established in 1979 in the context of the enactment of the Constitution of the Portuguese Republic in 1976 and is managed by the Ministry of Health.

The Ministry of Health is divided into three sectors: (1) the direct administration; (2) the indirect administration; and (3) the Public Enterprise Sector, comprising the Shared Services of the Ministry of Health (SPMS), local health units, hospital centres and public enterprise hospitals.3

The Ministry of Health is responsible for issuing the National Health Plan4 and the National Strategy for Quality in Health.5 Five regional health authorities (ARS) (which are public entities and part of the indirect administration of the state under the supervision of the Ministry of Health) are responsible for the implementation of the national health objectives set forth in said documents and have financial responsibility for primary and hospital care.

Despite the universal coverage of the SNS, there are other forms of financing the provision of healthcare services, which are specific to particular categories of citizen. There are groups of citizens with specific sickness schemes, usually designated as 'health subsystems'. These systems, which constitute the second vector of the healthcare system in Portugal, are formed by entities of a public or private nature that, by law or under contract, provide health benefits to a group of citizens or financially reimburse them for the corresponding charges. Membership of these subsystems is based on professional categories and covers beneficiaries who are still in work, retired workers and their family members. These subsystems are financed through the beneficiaries' contributions.

Until 2005, there were six health subsystems operating in the public sector that were integrated in that same year into the main subsystem, ADSE. ADSE comes under the indirect administration of the Ministry of Health (and is also subject to financial control from the Ministry of Finance) and now covers the provision of healthcare services to all public servants in a standardised form. At the end of 2015, the number of ADSE beneficiaries amounted to 1.25 million, including active staff, pensioners and family members, while it slightly decreased in 2016 to 1.22 million.6

Private health subsystems consist of entities of a private nature that, under contract, provide healthcare to a group of citizens or contribute financially to the corresponding charges. Such a contract is compulsory, resulting from a compulsory intra-group solidarity mechanism (with a professional or business matrix). The largest private subsystems are PT-ACS (the health subsystem for the employees of the telecommunications company Portugal Telecom) and SAMS (the health subsystem for banking and insurance employees).

Finally, the private insurance sector, the third vector of the healthcare system in Portugal,7 which is based on voluntary individual affiliation, operates under a free-market regime and is subject to the general legislation of the insurance sector. Since the early 1990s, the number of beneficiaries of health insurance has increased at a rate of more than 10 per cent per year, and in 2015, almost 2.7 million Portuguese citizens had health insurance. There are some cases where people can benefit from triple coverage: from the SNS, from a health subsystem and under private health insurance.8

Healthcare services are also be provided, on a more limited scale, by non-profit private operators with a charitable background, known as Holy Houses of Mercy.9 Anyone can access the healthcare services provided by the Holy Houses of Mercy (e.g., hospitals, Clinics of Physical Medicine and Rehabilitation, etc.), as they have agreements with both the SNS, as well as with health subsystems and insurers. In the case of agreements with the SNS, the Holy Houses of Mercy have agreements with the Ministry of Health for the provision of healthcare services, integrating them into the national healthcare network. In the case of subsystems (e.g. ADSE) and insurers, the user will have to be a beneficiary of one of these subsystems and the Holy Houses of Mercy must have an agreement in place with them to allow these beneficiaries to access healthcare services. There are currently 23 hospitals, 120 nursing homes, and other healthcare activities managed by the Holy Houses of Mercy.10

The healthcare system landscape has undergone changes in recent years. Portugal's bailout in 2011 and recourse to European Union mechanisms to avoid defaulting on its debts resulted in the execution of a memorandum of understanding (MoU) with the 'troika' of the European Commission, the International Monetary Fund and the European Central Bank. One of the most evident effects of the crisis involved the recessionary measures that governments were obliged to implement to reduce their sovereign debt.

To meet the purposes of the MoU, the Portuguese government initiated in 2011, among other reforms, a comprehensive reorganisation of the healthcare system to accomplish the MoU's objectives within the proposed time frames.11

As a result of these reforms, the Portuguese health system has been able to successfully balance the twin priorities of financial consolidation and continuous quality improvement. Despite these advances, a number of challenges remain in order to improve the quality of care in Portugal.12

II THE HEALTHCARE ECONOMY

i General

In addition to what is stated in the Constitution of the Portuguese Republic regarding the right to health protection, the general policy guidelines regarding the healthcare sector in Portugal are set out in Basic Law No. 48/90 of 24 August, as amended (the Healthcare Basic Law).

In addition to a network of public hospitals and primary healthcare facilities covering the entire Portuguese territory, there is a broad range of private healthcare services offered in Portugal, including private clinics of varying dimensions and private hospitals. There are several private entities in Portugal, profit and non-profit, operating networks of multiple private hospitals and clinics.

ii The role of health insurance

As mentioned in Section I above, there is no obligation for users of healthcare services to acquire healthcare insurance. This activity is governed by law and other instruments regulating insurance in Portugal. The insurance sector in Portugal is governed by the Authority for the Supervision of Insurance and Pension Funds.

iii Funding and payment for specific services

Pursuant to the Healthcare Basic Law, the SNS is financed primarily through transfers from the Portuguese state budget. Furthermore, pursuant to the Healthcare Basic Law, the Statutes of the SNS approved by Decree-Law No. 11/93, of 15 January, as amended, and Decree-Law No. 113/2011, of 29 November, as amended (Decree-Law 113/2011), which regulate access to the SNS services on the basis of moderating fees. Healthcare units of the SNS may also receive the following income:

a payment of healthcare services provided in particular rooms or other types or services not available for the majority of users;

b payment of healthcare services by third parties that have the legal or contractual responsibility to pay for healthcare such as healthcare subsystems or insurers;

c payment of healthcare services provided to non-beneficiaries of the SNS;

d donations; and

e moderating fees paid by users.

Moderating fees are charged to SNS users (with some exceptions applicable to certain categories of users as well as to certain types of healthcare services) with a view to incentivising a rational use of SNS resources and the control of public expenditure. Such fees are governed primarily by Decree-Law No. 113/2011 and by Ministerial Order No. 306-A/2011 of 20 December, as amended, setting a fixed fee for consultations (primary care and hospital outpatient visits), emergency visits, home visits, diagnostic testing and therapeutic procedures. Moderating fees are only due in ambulatory care.

Moderating fees will ideally be charged upon the provision of healthcare services, unless the user is unable to pay as a consequence of his or her health situation or a lack of financial means. Whenever the fees are not paid immediately, the user will be instructed to pay the relevant amount within 10 days. Non-payment of moderating fees is not a cause for refusing healthcare services.

The Portuguese government reimburses purchasers of prescription pharmaceutical products. The rules governing the reimbursement of prescription pharmaceutical products are set out in Decree-Law 97/2015 of 1 June 2015 (Decree-Law 97/2015). The decision to reimburse purchasers of pharmaceutical products must be made taking into account technical and scientific criteria as well as criteria of economic rationality, among other factors. Additional benefits are given to certain categories of patients, notably, pensioners who do not meet certain income thresholds and patients who suffer from certain types of illnesses.

Owing to mismatches between supply and demand, waiting lists in the SNS for surgery or consultations for certain medical specialties are often long. The SNS's offering of dental services is also limited, although Ministerial Order No. 301/2009, of 24 March, introduced the National Oral Health Promotion Programme, pursuant to which certain categories of patients are entitled to vouchers that are exchangeable for dentistry services. For these reasons there is strong demand for private-sector services in certain areas (e.g., dentistry or medical specialties).

Wellness services, alternative therapies and optics are usually funded by individuals, with the possibility of co-funding by private insurers or by the health subsystems. Certain types of beneficiaries (e.g., infants and adolescents, pregnant women, the elderly, and AIDS and HIV patients)) are entitled to certain specific additional benefits. In the specific case of the elderly, this group of beneficiaries can access additional benefits, such as co-funding for glasses up to a certain limit (under the Solidarity Supplement for the Elderly13 or exemption from payment of moderating fees. Furthermore, the Holy Houses of Mercy – in the context of the National Network of Integrated Continuous Care14 – provide the elderly with a set of mechanisms to give them adequate care, such as residential structures, day centres, home support services and continuous care units.

III PRIMARY / FAMILY MEDICINE, HOSPITALS AND SOCIAL CARE

Primary care is currently organised in Portugal on a geographical basis. The Group of Healthcare Centres (ACES), introduced under Decree-Law No. 28/2008, of 22 February, as amended, was created as a decentralised service of the ARS (which have directive powers over it) as a new way to guarantee improved direct access to healthcare for Portuguese citizens, which was previously assured by the healthcare centres regime, enacted by Decree-Law No. 60/2003 of 1 April. ACES is made up of healthcare providers with administrative autonomy, which agglomerate one or more healthcare centres. They are responsible for providing primary healthcare to the population of a specific geographic area. Even though ACES is intended to be the primary source of healthcare services, hospitals continue to be citizens' first choice.

It is also possible to receive basic primary healthcare through the Local Healthcare Systems (SLS), introduced by Decree-Law No. 156/99, of 10 May, which are made up of healthcare centres, hospitals and any other healthcare service providers or institutions, public or private, which operate within a certain local region. The SLS are created by means of an administrative order from the Minister of Health, following a proposal from the ARS and after consulting the local authorities.

Despite the international financial crisis in 2007, which limited public expenditure in the healthcare system, the private sector managed to find a way to keep its market share within the healthcare sector. One of the most important reforms within the hospital sector in Portugal in recent years was the development of public–private partnerships, enacted by Decree-Law No. 111/2012, of 23 May, as amended. Although the investment and operation of these healthcare units is private, they are nevertheless integrated into the SNS, which means that all SNS users have the same rights and duties as in any other public hospital or healthcare unit. Currently, there are four hospitals under this regime.15

IV the LICENSING OF HEALTHCARE PROVIDERS AND PROFESSIONALS

i Regulators

As mentioned in Section I above, the Ministry of Health is the central government entity responsible, among other things, for the execution and evaluation of the national health policy, for regulating and overseeing healthcare services and activities developed by the private sector and for the regulation, evaluation and inspection of the SNS.

Meanwhile, the ARS are the bodies responsible for supervising healthcare providers from the public, private or social sectors, with the exception of the pharmacy sector.

ii Institutional healthcare providers

The ARS, apart from being the bodies responsible for supervising healthcare activities, are also responsible for the entire licensing process of institutional healthcare providers. In accordance with Decree-Law No. 127/2014 of 22 August, as amended, the opening and functioning of a healthcare unit depends of the verification of the technical operating requirements applicable to each type of healthcare provider.

For an entity to operate as a healthcare provider it must obtain a licence for that purpose, except in the specific cases set forth in the law (in which case, a mere declaration of conformity is sufficient for the healthcare unit to function).

Without prejudice to criminal, disciplinary and civil liability and any other administrative sanctions that may apply, operating a healthcare unit without a licence is an administrative offence punishable with fines ranging from €4,000 to €44,891.81. In addition to this, and depending on the seriousness of the offence, additional sanctions may be imposed, such as the suspension of the activity of the healthcare unit subject to licensing for a maximum period of two years. If the licensing procedure is not settled, the healthcare unit may be definitively closed.

iii Healthcare professionals

The practice of medical doctors in Portugal is regulated by the Statutes of the Portuguese College of Medical Doctors, approved by Law No. 282/77 of 5 July, as amended.

The Portuguese College of Medical Doctors is a public professional association representing the medical doctor class in Portugal. To practise as a doctor, it is necessary to be registered with the Portuguese College of Medical Doctors. Registration can only be rejected on the basis of (1) a lack of required academic qualifications, (2) prohibition from practising the medical profession dictated by a court of law (if the decision can no longer be appealed), and (3) failure to pass a medical communication test that foreign doctors must comply with in order to assess their Portuguese language skills. The applicant is entitled to appeal the decision of the Portuguese College of Medical Doctors to a superior council or to the Portuguese administrative courts.

It is possible, under Decree-Law 341/2007 of 12 October, to obtain automatic recognition of foreign academic degrees that are of the same level and nature as and have objectives that are identical to the degrees of licenciado, mestre and doutor awarded by Portuguese higher-education institutions. Under this legal framework only public higher-education institutions are entitled to recognise a foreign degree as the corresponding referred to degrees. Following this recognition, international graduates can request their registration with the Portuguese College of Medical Doctors.

The practice of medicine without registration in the Portuguese College of Medical Doctors is considered as the crime of usurpation of functions under the Portuguese Penal Code, punishable with a prison sentence of up to two years or a fine of up to 240 days.

Dentistry, nursing and pharmacy are all also regulated professions that require prior inscription with a public association. Inscription in each of the respective public colleges governing the dentistry, nursing and pharmacy professions is governed by similar principles to those that govern inscription with the Portuguese College of Medical Doctors, notably in terms of academic requirements and the need to undertake adequate training in each of the aforementioned professions.

V NEGLIGENCE LIABILITY

i Overview

Law 67/2007 of 31 December sets forth the rules applicable to the state and other public entities' extra-contractual civil liability. Under this legal framework, the state and other legal entities governed by public law are exclusively liable for damages resulting from unlawful actions or omissions committed negligently by members of their bodies, officials or agents, in the performance of their administrative duties and resulting form that performance. This means that if the individuals working for the healthcare institution act with the expected level of diligence and in accordance with the technical rules of medical science, there will be no liability, regardless of the final outcome of the treatment (i.e., the obligation concerns the means and not the outcome).

The state and other legal persons governed by public law will also be liable in cases where the damage has not resulted from the conduct of a particular individual or whenever it is not possible to demonstrate liability for any act or omission, but must be attributed to the abnormal provision of the service. The law further clarifies what is considered an abnormal provision of the service.

Individuals will only be liable under this legal framework when their acts or omissions are caused by fault or when their diligence and care is significantly lower than what is expected for the position they hold. The public healthcare provider remains, nevertheless, jointly and severally liable.

Where private healthcare providers are concerned, and in the absence of specific legislation, the rules of contractual liability set forth in the Portuguese Civil Code will apply. Despite this, the rules of tort liability may also apply whenever it is not possible to resort to the rules of contractual liability in cases where it is not possible to demonstrate the existence of a contractual relationship between the patient and the doctor. Similarly to the public healthcare service providers, the obligations of private healthcare units (and their providers) concern the means and not the outcome.

ii Notable cases

Lisbon Court of Appeal (Case 1573/10.5TJLSB)

This case dates back to 2010 and relates to a civil action filed by a private hospital against the heirs of a patient who died. The hospital sought the payment of health expenses arising out of the patient's treatment while she was hospitalised. The defendants argued that they were not responsible for the payment of the fees, claiming that instead the hospital should pay compensation for damages arising from the patient's death, which happened as a result of a misdiagnosis.

The court considered this to be a situation of defective performance, and the defendants had to prove that there was an objective divergence between the acts carried out by the hospital and those that were deemed adequate for a certain result to be produced (in this case, to avoid the death of the patient). The court ruled that the hospital violated the general duties of care and that the misdiagnosis was a direct cause of the patient's death.

The novelty of this decision lies in the nature of the damages awarded to the defendants; there is no evidence that, even if the patient had been correctly diagnosed, the chances of survival would have been different. However, the defective performance of the hospital's duties (the court considered that the hospital had the contractual obligation to have acted differently, to have performed certain tests that would have allowed a correct diagnosis and adequate treatment) removed any possibility of the patient surviving. The theory of the 'loss of opportunity' refers to acts or omissions that have led to the loss of the opportunity of obtaining a benefit or avoiding an injury. There is a causal link between the hospital's conduct and the damage caused to the patient and, therefore, the hospital was liable for the damages caused to the patient and the heirs.

The court also decided that the expenses that the hospital claimed from the heirs were only incurred in an attempt to remedy the patient's condition, which was itself caused by the previous omissions and defective performance and, therefore, were not to be paid.

VI OWNERSHIP OF HEALTHCARE BUSINESSES

As already mentioned in Section IV.ii above, the opening and functioning of a healthcare unit depends of the verification of the technical operating requirements applicable to each type of healthcare provider. In addition to the technical operating requirements, the healthcare providers must also comply with hygiene, safety and public health requirements and their professionals must abide by the applicable ethical rules. Also, healthcare units must have an insurance policy in place covering all the inherent risks of the activity and the activity of its professionals.

There are no particular restrictions regarding the nationality of healthcare business owners.

Where competition issues are concerned, in the absence of specific rules applicable to the healthcare sector, the general rules of the Portuguese Competition Act (enacted by Law 19/2012 of 8 May) will apply.

VII COMMISSIONING AND PROCUREMENT

The procurement for the provision of healthcare services is made, at a national and centralised level, by the SPMS, a public entity, created in 2010 to operate under the Ministry of Health and Finance.16 The rules applicable to the formation, as well as to the substantive regime of administrative contracts in the context of the acquisition of products and services in the healthcare sector are set forth in Decree-Law 18/2008 of 29 January, as amended, which introduced the Public Contracts Code. Other rules also apply, such as the Administrative Procedure Code and the Procedure Code of the Administrative Courts.

The process related to public purchases in the health sector is processed in a single electronic contracting platform, centrally managed by the SPMS.17 The SPMS publishes on the platform a Public Health Supply Catalogue, which provides, among other things, updated information on existing goods and services under public procurement contracts and allows for the online consultation of the ongoing public tenders, as well as the online submission of supply proposals.

There are four main types of procurement procedures and two possible award criteria (the most economically advantageous tender and the lowest price). As a general rule, the choice of procedure is determined by the value of the contract (i.e., by the maximum value of the economic benefit, which, depending on the procedure adopted, can be obtained by the contractor). In some cases, the procedure to be followed is determined by the verification of specific circumstances provided by law.18 It is possible to challenge the procurement decisions either at an administrative or a judicial level.

As a final note, it is worth pointing out that the Minister of Health issued, on 16 January 2017, Order No. 851-A/2017 with recommendations aimed at preventing the violation of the principles of transparency, competition and pursuit of public interest in the area of public procurement.

VIII MARKETING AND PROMOTION OF SERVICES

The promotion and advertising of healthcare services and businesses was not formally regulated until 2015 with the enactment of Decree-Law 238/2015 of 14 October19 (Decree-Law 238/2015), which established the legal regime for health advertising practices and the general principles they must follow, and set out the practices considered to be misleading in this regard. Previously, in 2014, ERS issued a recommendation20 and an alert21 on advertising practices of healthcare providers, aimed at ensuring that any and all advertising messages referring to health services – regardless of format, form or medium of disclosure – should abide by the principles of lawfulness, truth, transparency and completeness.

With the exception of matters governed by special legislation, such as advertising for medicinal products and health products and state institutional advertising, this Decree-Law covers all advertising practices relating to conventional and non-conventional methods, complementary means of diagnosis and therapy, any treatments or therapies, namely those involving the use of cells.

This legal framework applies to any public or private entity that provides healthcare services or advertises products, regardless of the forms and means, related to the prevention and treatment of diseases, including the provision of diagnoses and any treatments or therapies.

All health advertising practices which, for any reason, induce or are likely to mislead the user as to whether to acquire a product or service, are forbidden by law. These advertising practices constitute an administrative offence punishable by fines ranging from €3,000 to €44,891.81. Additional sanctions, such as temporary prohibition (up to two years) from practising a professional or advertising activity and the loss of rights or benefits granted by regulatory authorities or public services (up to two years), may also be imposed depending on the seriousness of the offence and its potential impact.

The rules of the Portuguese Advertising Code, approved by Decree-Law 330/90, of 23 October are applicable, on a subsidiary basis, to these advertising practices.

IX FUTURE OUTLOOK AND NEW OPPORTUNITIES

The National Health Plan (2012–2016) (the Plan), which has been extended until 2020, is a basic element in defining health policies in Portugal and provides the main strategies for public health action to be implemented in the coming years. The Plan's main goals for the coming years are the decrease of premature (before the age of 70) mortality by 20 per cent, the increase of healthy life expectancy at age 65 by 30 per cent, the reduction of smoking in the population over 15 years old and the elimination of exposure to environmental smoke, as well as controlling the incidence and prevalence of obesity in young people and schoolchildren (with no quantitative objective attached).22

Another recent change regarding health promotion was the termination in 2012 of the four national vertical programmes on HIV/AIDS, oncological diseases, cardiovascular diseases and mental health, which were replaced with priority health programmes. Those resulted from the reorganisation of the four existing national vertical programmes as mentioned above and existing initiatives on respiratory diseases, tobacco control, healthy nutrition, control of antimicrobial resistance and diabetes.23

In the context of the administrative modernisation of the public sector, which has been a strong commitment of Portuguese governments in recent years, the healthcare system also provides positive signs. The Health Data Platform, launched in 2012, is a centralised system that records and shares clinical information, being duly authorised to do so by the Portuguese Data Protection Authority.24 This platform provides access to information for citizens who are SNS users and healthcare professionals within the SNS (hospitals, emergency rooms, primary care, continuing care network). This digital project has already been recognised by Portugal (it won the President of the Republic distinction in 2015 as well as the annual eGov Award) as a high-added-value project for citizens.25

Another important innovation worth emphasising is the implementation of the electronic prescription, which, as of 1 April 2016, is mandatory across the entire SNS. Another important change in the digital transformation of the SNS is telehealth, that is, the provision of healthcare services through teleconsultations, which allows the NHS to speak with all citizens, eliminating any geographical barriers. There are already several Local Health Units equipped with webcams and microphones that are prepared to provide medical services through teleconference.

Further to this, some measures have been recently approved to improve patient choice across SNS hospitals. From May 2016, SNS users can be referred to a hospital outside their local area, as long as waiting times for a given procedure or outpatient consultation are shorter than in their local area.26 The SNS launched its new website27 in February 2016, on which it provides information on waiting times regarding outpatient consultations for several specialties.28

Finally, the Portuguese government approved the National Strategy for the Ecosystem of Information 2020 (ENESIS 2020),29 which is aimed at improving access and information sharing by simplifying and dematerialising processes and documents, such as electronic prescriptions and the dispensing of drugs, processes associated with death and sick leave, the availability of data and services through the Health Data Platform30 and related portals and also providing public access to open data on the SNS website and at www.dados.gov.pt. The coordination and supervision of ENESIS 2020 are the responsibility of SPMS, under guidance of the respective ministry, ensuring its operationalisation and promotion within the scope of the SNS.

X CONCLUSIONS

As mentioned in Section I above, despite the significant reforms that have been carried out by the Portuguese government in recent years, particularly after 2011, a number of challenges are yet to be overcome.

According to a joint report issued by the Ministry of Health of Portugal, the European Observatory on Health Systems and Policies, and the Regional Office for Europe of the World Health Organization in April 2018,31 Portugal has a strong record of developing coherent and well-focused health plans, but there are significant weaknesses in linking and implementing plans at the national, regional and local levels. The future vision for healthcare delivery will need better facilities, and better equipment to improve the delivery of healthcare services and provide staff motivation. The increase in the use of information technology is also an aspect that will bring significant benefits as it contributes to improving health literacy and access to care, increasing accountability and better informing the planning and management of health services. Periodic analysis by the different agents of the healthcare system on the weaknesses of the system, as well as focused action and careful monitoring and evaluation will make it possible to meet Portuguese healthcare needs more effectively and efficiently.


Footnotes

1 Francisco Brito e Abreu is a partner and Joana Mota is a managing associate at Uría Menéndez – Proença de Carvalho. The authors would like to acknowledge the contribution of their colleagues José Maria Rodrigues (senior associate), Rita Canto e Castro and Sebastião de Carvalho Lorena (both trainee lawyers) in the preparation of this review.

2 Article 64 (2) of the Constitution of the Portuguese Republic.

3 The organisation chart of the Ministry of Health: www.sns.gov.pt/institucional/entidades-de-saude/.

7 Evaluation of the contracting model of healthcare providers by subsystems and health insurance issued by the Health Regulatory Authority (ERS), available at: www.ers.pt/uploads/writer_file/document/70/Subsistemas_Seguros.pdf.

8 Health Systems in Transition – Portuguese Health system review 2017, Jorge de Almeida Simões, Gonçalo Figueiredo Augusto, Inês Fronteira, Cristina Hernandez-Quevedo: www.plataforma.org.pt/c/document_library/get_file?uuid=532b8c33-e4d4-4af3-972b-1dd46542b736&groupId=18.

9 'Holy Houses of Mercy are brotherhoods of laymen inspired by the Catholic faith, whose objective is to help victims of any form of misery, and whose work includes feeding the hungry, curing the sick, and other types of social work.' The role of private non-profit healthcare organisations in NHS Systems: implications for the Portuguese hospital devolution Program, 2016, Álvaro S Almeida: http://wps.fep.up.pt/wps/wp577.pdf.

13 Additional information on the beneficiaries entitled to this social benefit can be found here: https://www.sns.gov.pt/sns-saude-mais/comparticipacoes/.

14 This national network was enacted by Decree-Law No. 101/2006, of 6 June, as amended, and is operated by the SNS and the Social Security System, consisting of a set of institutions, public and private, that provide continuous care and social support for people in situations of dependency, both in their homes and in inpatient units.

15 Hospital Beatriz Ângelo, Hospital de Braga, Hospital Cascais Dr. Josá Almeida and Hospital Vila Franca de Xira. Additional information on the contracting model of the PPP can be found at: www.acss.min-saude.pt/2016/10/12/parcerias-publico-privadas/.

16 It was formally incorporated under Decree-Law 19/2010, of 22 March. Further information about the SPMS can be found at: http://spms.min-saude.pt/en/spms/.

17 In accordance with Ruling 227/2014, of 6 November, as amended. The electronic contracting platform is available at: https://community.vortal.biz/PRODSTS/Users/Login/Index?SkinName=SPMS.

18 Further information on the procurement process can be found at: http://spms.min-saude.pt/wp-content/uploads/2016/01/Manual-de-Contratação-Pública.pdf.

19 And further regulated by Regulation 1058/2016 of 24 November.

23 Health Systems in Transition – Portuguese Health system review 2017, Jorge de Almeida Simões, Gonçalo Figueiredo Augusto, Inês Fronteira, Cristina Hernandez-Quevedo.

24 The authorisation can be found at: www.cnpd.pt/bin/decisoes/Aut/10_940_2013.pdf.

26 Decision No. 6170-A/2016, of 9 May 2016.

28 Health Systems in Transition – Portuguese Health system review 2017, Jorge de Almeida Simões, Gonçalo Figueiredo Augusto, Inês Fronteira, Cristina Hernandez-Quevedo.

29 Resolution of the Council of Ministers 62/2016, of 17 October.

30 See Section III above.