The planning and resource allocation in the Portuguese health care system is centralized, even though it accounts for some territorial structures [11]. Despite some attempts at decentralization, the idea prevails that the benefits arising from decentralization are dubious, it might increase the complexity of the system and most likely it would increase inequity [28].

Hospital management has taken different forms, such as public enterprises and public and private partnerships, and the payment system is grounded on a negotiated contract, which in turn is based on DRG (diagnostic related groups). grouping, fee for services, fee per chronic patient and pay-for-performance. These models of hospital management have been giving the health system quality and efficiency [19].

Another strength of the system that should be mentioned is centralized procurement, not only for the hospital sector but for the whole set of public health units. This enables the Central Purchasing Authority to control costs through price-volume agreements [29].

Finally, the last strength of the PHS to be mentioned is the separation of the provider, regulator and payer. This contributes to the good governance of the system [2].

Considering the principles of the PHS, the constitution, the general organization and management of the health care services, the Portuguese people ought to have access to primary, hospital and long term care [2].

The PHS is mainly financed by taxes, but it is also financed by occupation-based health insurance, either public or private, for some occupational categories [2]. The public insurance arrangements (the subsystems) are additional to the national public health system and cover civil servants, the military and police forces. At present, and after the change of rules for financing under the Memorandum of Understanding (MoU), these public insurance arrangements have become financially self-sustainable [29].

The organization of the health care services reflects a weak rationalization of the whole system. The PHS is over reliant on hospital care [20]: it is estimated that around 30% of hospital intervention could be handled in primary care [34]. However, the primary care level has failed to develop the provision capacity to respond to demand (more than a million people have no assigned family doctor) and long-term care is insufficient and inadequately developed to match the community’s needs [20].

Another potential weakness of the health system design is the way the public and private sectors are interrelated without their boundaries being precisely defined, financial and equity problems are raised [2].

The management of the system is, in general, weak and it needs improvement at both the organizational and leadership levels [1]. It is often argued that health professionals tend to be inflexible in their roles within the healthcare system and also that leaders and health professionals work with their backs turned to one another, without the communication needed to improve quality and efficiency [e.g.: 1]. Good governance, transparency and accountability as well as performance orientation and effective collaboration are organizational goals yet to be achieved.

Despite the extensive network of primary care units in Portugal, there is a large number of people who are not enrolled with a family doctor and do not have easy access to primary care. Dental care and complementary and alternative medicines such as acupuncture and homeopathy are not included in the Portuguese health system [2]. Moreover, long term, integrated and continuous care, as well as palliative care are clearly in short supply [20]. In 2014, there were 110 355 people dependent on someone else due to poor health status and of these about 44% are confined to bed. But the number of available beds for integrated and continuous care was only 6642 [35].

Total health expenditure as a percentage of the Gross Domestic Product (GDP) was about 9.8% in 2010 and 9.1% in 2013, which is not far from the OECD average. However, the health expenditure per capita in 2013 was about 2514 USD PPP, while the OECD average is around 3450 USD PPP [19].

Other financial weaknesses worth mentioning are:

• a reduction of nearly 10% in real public health expenditure in 2012 [36]
• a reduction of 2.2% in the annual real average growth rate of health expenditure per capita between 2009 and 2011 [37]
• debts and arrears in hospitals continue to be a significant problem. Hospital debts were around €1.314 billion in 2014. Fortunately, in this same year there was a €271 million fall in debts; the amount of arrears has fallen nearly 70% since 2011 [5].
• out of pocket expenditures, as a percentage of the total health expenditures, has been increasing and it is one of the highest in Europe [4, 19, 38]

The right to health [43], the core of any health system, is guaranteed by the Portuguese constitution. The PHS is defined by universal access to all residents and with low payments at the point of use. Its goal is to protect the health of the population living in Portugal. Health policies should promote equal access to health care for the citizens, irrespective of economic condition and geographic location, and they should ensure equity in the distribution of resources and use of health care services.

The design and definition of the PHS accomplishes the four values listed in the Statement on Common Values and Principles [44], which underpin all the European health systems: universal coverage; solidarity in financing; equity of access; and provision of high quality health care.

Patient experience of ambulatory care is quite positive in terms of doctors spending enough time with patients at appointments, providing easy-to-understand explanations, giving the opportunity to ask questions and raise concerns and involving patients in decisions about care and treatment [19].

A quality competitive context has been created within hospitals with the publication of a Ranking of Hospitals. This ranking aims to measure hospital performance for admitted patients and it covers all public hospitals [45].

The amount of daily smoking has shown a declining trend for male adults [4, 32]. The average amount of fruit and vegetables eaten per person is about 275 kg/year which is above the EU28 average [38].

The WHO proposal on how to assess a health system’s performance is based on sophisticated statistical analysis. The overall healthcare system performance was measured for 191 countries [46]. The PHS ranked 12^th best out of 191 WHO members and 6th within the EU countries.

Bloomberg rankings [47], in 2014, have rated countries according to the quality of the health system. Based on the efficiency of their healthcare systems (140 countries), the PHS comes 12^th out of 40 European countries, but is below the median score.

PHS has shown a strong resilience during economic and financial crisis. Despite the strong cuts, the reported statistics on health have not followed an identical path of worsening [20, 36].

The most common reason cited to justify unmet health care needs is tight disposable income. In 2013, the percentage of people self-reporting unmet needs for medical examination because they could not afford it is 2.4%, which is the EU average [4]. But the figure for England is 0.1%.

In 2014, 5.5% of the population over 16 y.o. reported unmet health care needs and 18.8% reported unmet dental care. Of these, 53.5% reported financial constraints on obtaining medical care, while 82.5% said the same for dental care [48].

In Portugal, the figure for care needs unmet due to financial constraints, transport costs or waiting time, for the lowest level of income, is the same as the OECD average [19]. Concerning unmet dental care, the figure for Portugal is higher (23.7%) than the OECD average (9.6%), in the population with the lowest income. Additionally, the weight of medical expenditures in the final household consumption is greater in Portugal than in other European countries. On average it represents 3.9%, while the figure for the OECD is 2.8% and 1.4% for the UK [19].

Another noteworthy weakness of the Portuguese health system concerns access to new drugs and therapies. New drugs are very often launched considerably later than in higher-priced EU markets [49], one well known example being the hepatitis C drug [50]. The result is poorer public health, and even higher patient mortality.

The PHS fails to public cover most dental care and almost every complementary and alternative medicine. People using these health services have to pay for them in full. Moreover, most public health services charge some fee at the point of use [51] and most pharmaceuticals offer only a small rate of reimbursement [2].

Regarding primary care, a significant number of people do not have family doctor. About 12% of Portuguese do not have an assigned family doctor [52], which means that nearly 1233236 of people face some difficulty in accessing primary care.

On the other hand, in hospital care, a major weakness is the high number of hospital infections, one of the worst in Europe [53] and post-operative sepsis in abdominal surgeries is the second highest in the OECD countries [19]. The numbers have increased so much that Fundação Calouste Gulbenkian (FCG Foundation)¹ has decided to create a contest called Stop hospital infections [1] which aims to reduce infections by 10% in the next three years.

Another weakness that is to be noted is that the deaths following an acute myocardial infarction and after admission for ischemic stroke are higher than the OECD average [20].

The trend for female smoking on daily basis has been increasing [4, 38]; the alcohol consumption per capita is one of the highest in the OECD countries [19]; child obesity is a current problem, reflecting unhealthy lifestyles chosen by

parents; the prevalence of adult obesity is also an issue, the rate being the third highest in the EU15 in 2006 [54]; physical activity is one of the lowest in the European Union, while the number of those who never exercise is one of highest, around 64% of adults never do any physical exercise [55]. Mental health has declined over the last few years. The prevalence of mental disorders in Portugal is one of the highest in Europe at about 22.8% [56, 57].

In 2010, Joumard et al. [10] compared health care systems from different countries. They placed the PHS in Group 5, which has the following features: public provision and public insurance, gate-keeping, limited choice of providers and soft budget constraint. The ranking of countries in this Group, from best to worst, is as follows: Denmark, Finland, Spain, Portugal and Mexico. Across the all set of country groups, it can be observed that Portugal performs below the OECD average and it is among the 10 worst performing countries, out of 29 OECD countries.

The international comparisons continue to show that there is room for improvement in both quality and efficiency.

First, patient empowerment means that people need to be engaged with health strategies to prevent illnesses and they need to feel empowered to manage their own health. Educating people for health issues can contribute to a smoothly functioning health system, but providing accredited high-quality information also helps people to manage their own health condition [65, 66].

Second, the development of a person-centered model of healthcare is a challenge that has emerged from the increasing prevalence of chronic diseases in the population. New models of providing health care services will be developed or enlarged, where the patient can become the stakeholder in their care, where home can be the preferred location, where information technology plays a significant role and coordination across the health care services is central [65, 66].

Patient records create a huge amount of information and this digitalized information feeds the possibilities of person-centered and personalized health care. This large amount of information supplies a medicine based on prediction and prevention instead of a breaking and fixing approach. In addition, health authorities may be able to gather plenty of electronic information about patients, such as, information provided by health monitors, ventilators or wearable devices; geographic information system technology, wireless communications and GPS provide more data that can be used to improve both the individual’s health and how the health system functions. A wide range of technology, from apps to personal health devices, which gathers information and helps to monitor peoples’ health; the electronic patient record centralizes a set of health information which contributes to faster and easier decisions on one’s health [65, 66].

Finally, big data analysis is already at stack level. Almost everything that determines health can be stored in databases. This information can be used to identify patterns of diseases, links between causes and symptoms, efficacy of treatments and adverse event drivers. Big data analysis will help to improve the efficiency of the health system [67].

The PHS has much to gain in quality and performance by improving its ability extract the benefits offered by the digitalization of the health sector.

HTA has been used to search for the best value for money in health care for some years now and the experiences in other countries favor using it. HTA does not only apply to pharmaceuticals, it is for medical technologies and de-investment decisions, too [62]. The importance of health technology assessment in recognizing the value of innovation within limited health system resources justifies the creation or implementation of an organization, body or exploiting the more usual university consulting services to support decision making in the health care sector.

Portugal has a national system of health technology assessment, called SiNATs, which was created in 2014. At present, the assessment is mainly restricted to drugs but it aims to assess health technologies and health programs [68]. Other countries’ experience, such as National Institute for Health and Care Excellence (NICE) in the United Kingdom (UK) [69] provide a source of information about the good practice and governance of HTA. Moreover, having a national body for HTA and the European cooperation on this issue through the EUnetHTA encourages the exchange of information and the harmonization of decision making about coverage [70].

iv) A final point to highlight one more opportunity for the PHS: continuous quality improvement. This includes quality governance [71], and the provision of primary and hospital care. This both improves quality, efficiency and efficacy. The adoption of good clinical practices and the use of evidence based practices together with forward-looking leadership and the involvement of society as a whole support such quality improvement.

They demand transparency of data and processes. As a consequence, healthcare organizations will need to focus on how quality outcomes can be published in a meaningful way for patients. Patient safety is the major focus of patient advocacy groups and healthcare leaders. They will enforce deeper investigations of medication errors, hospital acquired infections, wrong site surgery and pressure sores, like never before.