Public-private partnerships in primary healthcare

Decree-Law no. 81/2024, of October 31 was published, amending Decree-Law no. 103/2023, which regulates the legal framework for the organization and operation of family health units (USF). The main change introduced by the new Decree-Law is to clarify the regime for the operation of USF organized under model C and, in particular, determine that these USF may be contracted with the social or private sector, with a view of improving access to health care for the population. This was one of the priority measures in the Health Emergency and Transformation Program of the current Government.

This model allows private entities, such as companies, non-profits, and professional consortia, to operate primary healthcare units under public contracts within the National Healthcare Service (NHS). These changes aim to bring agility and efficiency to the delivery of primary healthcare to the population, while adhering to the fundamental principles of universal access and service quality.

It is the responsibility of the Executive Directorate of the National Health Service (DE-SNS) to annually identify the needs for the opening of model C USFs with the private and social sectors, according to criteria related to the coverage rate and assignment of family doctors to users.

For now, Order no. 14021/2024, has identified the need to create 20 USF-C, distributed in municipalities in the Lisbon and Tagus Valley region (ten), Leiria (five) and the Algarve (five). However, it is immediately noticeable that this Order, which established the number of model C family health units to be set up in the year of 2024, was only published on November 27, 2024.

The process of application and adjudication for USF Model C is regulated by Ordinance 302/2024/1, of November 25, and begins with the publication of an official notice, detailing the procedure’s terms and requirements, in particular, the terms of reference that should govern the operation of the USF model C, namely with regard to the care activity to be ensured, its objectives, indicators and results to be achieved in the areas of performance, service portfolio and quality, as well as the most appropriate financing system. These shall be defined by DE-SNS and the Central Administration of the Health System (ACSS) together.

Interested private or social sector entities must submit an application which includes the identification of the promoting entity, proposed clinical coordinator, and team composition or resource needs.

The application is reviewed by ACSS within 45 days, which evaluates the financial, human, and physical resource adequacy of the proposal. In the event of a favorable decision, the ACSS draws up a favorable technical opinion and the adjudication follows either public procurement rules or health contract provisions under the Health Bases Law. The start date of the provision of care in the USF model C is then set out in the contract signed with the respective Local Health Unit (ULS).

Once operational, model C USF will be subject to monitoring and oversight by the competent authorities. Monitoring is carried out by the contracting ULS on a quarterly basis, and by DE-SNS and ACSS annually. These evaluations assess compliance with the contractual terms, service quality, and operational performance and the reports of the authorities must be made publicly available on relevant institutional websites. The agreements with the ULS will also include penalties for non-compliance, adding an extra layer of accountability for private operators. Together, these measures aim to support transparency and encourage adherence to the high-performance benchmarks outlined in the contractual agreements and legal requirements for USF Model C operations.

For private entities ready to embrace this innovative model, the USF Model C represents an opportunity to contribute to the enhancement of access to Portugal’s primary healthcare and bridging existing gaps. It remains to be seen whether private and social entities are willing to take the risk in adopting the new and innovative USF Model C and with which level of cooperation they will be met by the competent entities. Additionally, the legal framework established by the Government will have to prove to be adequate in addressing the challenges and practical issues that may emerge as these entities begin to operate within this model. The coming months will be crucial in determining the viability and effectiveness of this new approach to primary healthcare delivery.