{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,12]],"date-time":"2025-10-12T04:39:15Z","timestamp":1760243955986,"version":"build-2065373602"},"reference-count":48,"publisher":"MDPI AG","issue":"22","license":[{"start":{"date-parts":[[2022,11,10]],"date-time":"2022-11-10T00:00:00Z","timestamp":1668038400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"project \u201c1st.IndiQare\u2014Quality indicators in primary health care: validation and implementation of quality indicators as an assessment and comparison tool\u201d","award":["POCI01-0145-FEDER-030766","INSA\/2011EXT554"],"award-info":[{"award-number":["POCI01-0145-FEDER-030766","INSA\/2011EXT554"]}]},{"name":"project \u201cContracting in primary health care in Portugal: Research and practice\u201d","award":["POCI01-0145-FEDER-030766","INSA\/2011EXT554"],"award-info":[{"award-number":["POCI01-0145-FEDER-030766","INSA\/2011EXT554"]}]},{"name":"Laidlaw Foundation","award":["POCI01-0145-FEDER-030766","INSA\/2011EXT554"],"award-info":[{"award-number":["POCI01-0145-FEDER-030766","INSA\/2011EXT554"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Equal and adequate access to healthcare is one of the pillars of Portuguese health policy. Despite the controversy over commissioning processes\u2019 contribution to equity in health, this article aims to clarify the relationship between socio-economic factors and the results of primary healthcare (PHC) commissioning indicators through an analysis of four years of data from all PHC units in Portugal. The factor that presents a statistically significant relationship with a greater number of indicators is the organizational model. Since the reform of PHC services in 2005, a new type of unit was introduced: the family health unit (USF). At the time of the study, these units covered 58.1% of the population and achieved better indicator results. In most cases, the evolution of the results achieved by commissioning seems to be similar in different analyzed contexts. Nevertheless, the percentage of patients of a non-Portuguese nationality and the population density were analyzed, and a widening of discrepancies was observed in 23.3% of the cases. The commissioning indicators were statistically related to the studied context factors, and some of these, such as the nurse home visits indicator, are more sensitive to context than others. There is no evidence that the best results were achieved at the expense of worse healthcare being offered to vulnerable populations, and there was no association with a reduction in inequalities in healthcare. It would be valuable if the Portuguese Government could stimulate the increase in the number of working USFs, especially in low-density areas, considering that they can achieve better results with lower costs for medicines and diagnostic tests.<\/jats:p>","DOI":"10.3390\/ijerph192214819","type":"journal-article","created":{"date-parts":[[2022,11,10]],"date-time":"2022-11-10T19:16:23Z","timestamp":1668107783000},"page":"14819","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Healthcare Equity and Commissioning: A Four-Year National Analysis of Portuguese Primary Healthcare Units"],"prefix":"10.3390","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8290-5297","authenticated-orcid":false,"given":"Ant\u00f3nio","family":"Pereira","sequence":"first","affiliation":[{"name":"Family Health Unit, Unidade de Sa\u00fade Familiar Prelada, ACES Porto Ocidental, 4250-113 Porto, Portugal"},{"name":"PHC\u2014Commissioning Department, Northern Regional Administration of Health, 4000-447 Porto, Portugal"},{"name":"CINTESIS\u2014Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5677-1539","authenticated-orcid":false,"given":"Andr\u00e9","family":"Biscaia","sequence":"additional","affiliation":[{"name":"CINTESIS\u2014Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal"},{"name":"Family Health Unit, Unidade de Sa\u00fade Familiar Marginal, ACES Cascais, ARS Lisboa e Vale do Tejo, 2765-618 S\u00e3o Jo\u00e3o do Estoril, Portugal"}]},{"given":"Isis","family":"Calado","sequence":"additional","affiliation":[{"name":"University College London Medical School, London WC1E 6DE, UK"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2113-9653","authenticated-orcid":false,"given":"Alberto","family":"Freitas","sequence":"additional","affiliation":[{"name":"CINTESIS\u2014Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2727-4402","authenticated-orcid":false,"given":"Andreia","family":"Costa","sequence":"additional","affiliation":[{"name":"Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), Nursing School of Lisbon (ESEL), 1600-096 Lisbon, Portugal"},{"name":"Cat\u00f3lica Research Centre for Psychological, Family and Social Wellbeing, Faculdade de Ci\u00eancias Humanas, Universidade Cat\u00f3lica Portuguesa, 1649-023 Lisbon, Portugal"},{"name":"Instituto de Sa\u00fade Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, 1099-085 Lisbon, Portugal"}]},{"given":"Anabela","family":"Coelho","sequence":"additional","affiliation":[{"name":"Comprehensive Health Research Centre (CHRC), Nursing Department, University of \u00c9vora, 7004-516 Evora, Portugal"},{"name":"H&TRC\u2014Health & Technology Research Center, ESTeSL\u2014Escola Superior de Tecnologia da Sa\u00fade, Instituto Polit\u00e9cnico de Lisboa, 1990-096 Lisbon, Portugal"},{"name":"Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade NOVA de Lisboa, 1349-008 Lisbon, Portugal"}]}],"member":"1968","published-online":{"date-parts":[[2022,11,10]]},"reference":[{"key":"ref_1","unstructured":"Arnold, J.M., and Rodrigues, F.C. (2015). Reducing Inequality and Poverty in Portugal, OECD."},{"key":"ref_2","unstructured":"Portugal (1997). Constitui\u00e7\u00e3o da Rep\u00fablica Portuguesa de 2 de Abril de 1976, Revista Pelas Leis Constitucionais Nos. 1\/82, 1\/89, 1\/92 E 1\/97: Lei Do Tribunal Constitucional, Coimbra Editora."},{"key":"ref_3","unstructured":"Assembleia da Rep\u00fablica (1990). Lei 48\/90: Lei de Bases da Sa\u00fade, Di\u00e1rio da Rep\u00fablica."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"733","DOI":"10.1002\/ajhb.22440","article-title":"Socio-demographic and behavioral risk factors associated with the high prevalence of overweight and obesity in Portuguese children","volume":"1","author":"Bingham","year":"2013","journal-title":"Am. J. Hum. Biol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"50","DOI":"10.1016\/j.ypmed.2009.11.004","article-title":"Overall and central obesity incidence in an urban Portuguese population","volume":"50","author":"Lopes","year":"2010","journal-title":"Prev. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1016\/j.healthplace.2012.10.005","article-title":"Perceptions of neighborhood environments and childhood obesity: Evidence of harmful gender inequities among Portuguese children","volume":"19","author":"Nogueira","year":"2013","journal-title":"Health Place"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"434","DOI":"10.1002\/ajhb.22384","article-title":"The associations of SES, obesity, sport activity, and perceived neighborhood environments: Is there a model of environmental injustice penalizing Portuguese children?","volume":"25","author":"Nogueira","year":"2013","journal-title":"Am. J. Hum. Biol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"375","DOI":"10.1037\/a0015831","article-title":"Predictors of mental health among adolescents from immigrant families in Portugal","volume":"23","author":"Neto","year":"2009","journal-title":"J. Fam. Psychol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"22","DOI":"10.5539\/gjhs.v6n4p22","article-title":"Psychosocial determinants of mental health and risk behaviours in adolescents","volume":"6","author":"Carvalho","year":"2014","journal-title":"Glob. J. Health Sci."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"e000595","DOI":"10.1136\/bmjopen-2011-000595","article-title":"An ecological study on the geographic patterns of ischaemic heart disease in Portugal and its association with demography, economic factors and health resources distribution","volume":"2","year":"2012","journal-title":"BMJ Open"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"4985","DOI":"10.1016\/j.ijcard.2013.07.131","article-title":"Influence of socioeconomic status on therapy and prognosis after an acute heart failure episode","volume":"168","author":"Bettencourt","year":"2013","journal-title":"Int. J. Cardiol"},{"key":"ref_12","unstructured":"Van Doorslaer, E., and Masseria, C. (2004). Income-Related Inequality in the Use of Medical Care in 21 OECD Countries, OECD."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"280","DOI":"10.1016\/j.jhealeco.2008.09.008","article-title":"Measurement of horizontal inequity in health care utilisation using European panel data","volume":"28","author":"Jones","year":"2009","journal-title":"J. Health Econ."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"145","DOI":"10.1186\/s12939-017-0642-7","article-title":"Evolution and financial cost of socioeconomic inequalities in ambulatory care sensitive conditions: An ecological study for Portugal, 2000\u20132014","volume":"16","author":"Costa","year":"2017","journal-title":"Int. J. Equity Health"},{"key":"ref_15","unstructured":"Dire\u00e7\u00e3o-Geral de Sa\u00fade (2015). Plano Nacional de Sa\u00fade. Revis\u00e3o e Extens\u00e3o a 2015, Dire\u00e7\u00e3o-Geral de Sa\u00fade."},{"key":"ref_16","unstructured":"World Health Organization (2010). WHO Evaluation of the National Health Plan of Portugal (2004\u20132010), WHO."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"709","DOI":"10.1016\/j.healthpol.2021.02.008","article-title":"The effect of commissioning on Portuguese Primary Health Care units\u2019 performance: A four-year national analysis","volume":"125","author":"Ramalho","year":"2021","journal-title":"Health Policy"},{"key":"ref_18","first-page":"1","article-title":"Portugal: Health System Review","volume":"19","author":"Augusto","year":"2017","journal-title":"Health Syst. Transit."},{"key":"ref_19","unstructured":"Kruse, F.M., Ligtenberg, W.M.R., Oerlemans, A.J.M., Groenewoud, S., and Jeurissen, P.P.T. (2022, October 30). How the Logics of the Market, Bureaucracy, Professionalism and Care Are Reconciled in Practice: An Empirical Ethics Approach\u2014BMC health Services Research. BioMed Central. BioMed Central. Available online: https:\/\/bmchealthservres.biomedcentral.com\/articles\/10.1186\/s12913-020-05870-7."},{"key":"ref_20","first-page":"7","article-title":"The health of the Portuguese over the last four decades","volume":"130","author":"Santana","year":"2018","journal-title":"M\u00e9diterran\u00e9e"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"856","DOI":"10.1126\/science.417400","article-title":"The quality of medical care","volume":"200","author":"Donabedian","year":"1978","journal-title":"Science"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"174","DOI":"10.1016\/j.bjae.2019.02.003","article-title":"What is clinical governance?","volume":"19","author":"Macfarlane","year":"2019","journal-title":"BJA Educ."},{"key":"ref_23","unstructured":"(2022, September 13). SPMS, ACSS, USF-AN. Bilhete de Identidade do Cuidados de Sa\u00fade Prim\u00e1rios 2017. Available online: https:\/\/bicsp.min-saude.pt\/."},{"key":"ref_24","unstructured":"Faculty of Medical Leadership and Management (2015). Commissioning: What\u2019s the big deal?. NHS Engl., 130, 1. Available online: https:\/\/www.nhs.uk\/NHSEngland\/thenhs\/about\/Documents\/Commissioning-FINAL-2015.pdf."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"533","DOI":"10.1017\/S0047279412000232","article-title":"Commissioning in the English National Health Service: What\u2019s the problem?","volume":"41","author":"Checkland","year":"2012","journal-title":"J. Soc. Policy"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1071\/PY15037","article-title":"Something old, something new, something borrowed, something blue? Reviewing the evidence on commissioning and health services","volume":"22","author":"Robinson","year":"2016","journal-title":"Aust. J. Prim. Health"},{"key":"ref_27","first-page":"7","article-title":"O processo de contratualiza\u00e7\u00e3o na sa\u00fade em Portugal (1996\u20132005)","volume":"9","author":"Escoval","year":"2010","journal-title":"Rev. Port. Sa\u00fade P\u00fablica"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"80","DOI":"10.1111\/hsc.12464","article-title":"Commissioning and equity in primary care in Australia: Views from Primary Health Networks","volume":"26","author":"Henderson","year":"2018","journal-title":"Health Soc. Care Commun."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Boeckxstaens, P., Smedt, D.D., Maeseneer, J.D., Annemans, L., and Willems, S. (2011). The equity dimension in evaluations of the quality and outcomes framework: A systematic review. BMC Health Serv. Res., 11.","DOI":"10.1186\/1472-6963-11-209"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"a2030","DOI":"10.1136\/bmj.a2030","article-title":"Effect of social deprivation on blood pressure monitoring and control in England: A survey of data from the quality and outcomes framework","volume":"29","author":"Ashworth","year":"2008","journal-title":"BMJ"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1083","DOI":"10.1111\/j.1464-5491.2008.02544.x","article-title":"Introduction of a new incentive and target-based contract for family physicians in the UK: Good for older patients with diabetes but less good for women?","volume":"25","author":"McGovern","year":"2008","journal-title":"Diabet Med."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"728","DOI":"10.1016\/S0140-6736(08)61123-X","article-title":"Effect of financial incentives on inequalities in the delivery of primary clinical care in England: Analysis of clinical activity indicators for the quality and outcomes framework","volume":"372","author":"Doran","year":"2008","journal-title":"Lancet"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"e331","DOI":"10.1016\/S2214-109X(20)30480-0","article-title":"Socioeconomic inequalities in the quality of primary care under Brazil\u2019s national pay-for-performance programme: A longitudinal study of family health teams","volume":"9","author":"Kovacs","year":"2021","journal-title":"Lancet Glob. Health"},{"key":"ref_34","unstructured":"Biscaia, A., Pereira, A., Antunes, A., Machaqueiro, S., Rosa, M., Nogueira, P., and Lap\u00e3o, L. (2016). Contratualiza\u00e7\u00e3o nos Cuidados de Sa\u00fade Prim\u00e1rios: Investiga\u00e7\u00e3o e Pr\u00e1tica\u2014Uma Abordagem Conjunta, Minist\u00e9rio da Sa\u00fade\/INSA IP. INSA\/2011EXT554."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1177\/0095798418771807","article-title":"Exploratory factor analysis: A guide to best practice","volume":"44","author":"Watkins","year":"2018","journal-title":"J. Black Psychol."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Buja, A., Solinas, G., Visca, M., Federico, B., Gini, R., Baldo, V., Francesconi, P., Sartor, G., Bellentani, M., and Damiani, G. (2016). Prevalence of Heart Failure and Adherence to Process Indicators: Which Socio-Demographic Determinants Are Involved?. Int. J. Environ. Res. Public Health, 13.","DOI":"10.3390\/ijerph13020238"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"33","DOI":"10.1093\/fampra\/cmm073","article-title":"The Effect of the UK Incentive-Based Contract on the Management of Patients with Coronary Heart Disease in Primary Care","volume":"25","author":"McGovern","year":"2008","journal-title":"Fam. Pract."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"2354","DOI":"10.1161\/01.STR.0000236067.37267.88","article-title":"Effect of the UK Incentive-Based Contract on the Management of Patients with Stroke in Primary Care","volume":"37","author":"Simpson","year":"2006","journal-title":"Stroke"},{"key":"ref_39","first-page":"441","article-title":"The Relationship between Social Deprivation and the Quality of Primary Care: A National Survey Using Indicators from the UK Quality and Outcomes Framework","volume":"57","author":"Ashworth","year":"2007","journal-title":"Br. J. Gen. Pract. J. R. Coll. Gen. Pract."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"e2405","DOI":"10.1136\/bmj.e2405","article-title":"Exempting Dissenting Patients from Pay for Performance Schemes: Retrospective Analysis of Exception Reporting in the UK Quality and Outcomes Framework","volume":"344","author":"Doran","year":"2012","journal-title":"BMJ"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"404","DOI":"10.2337\/dc08-0912","article-title":"Impact of Pay for Performance on Ethnic Disparities in Intermediate Outcomes for Diabetes: A Longitudinal Study","volume":"32","author":"Millett","year":"2008","journal-title":"Diabetes Care"},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Muggah, E., Dahrouge, S., and Hogg, W. (2012). Access to Primary Health Care for Immigrants: Results of a Patient Survey Conducted in 137 Primary Care Practices in Ontario, Canada. BMC Fam. Pract., 13.","DOI":"10.1186\/1471-2296-13-128"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1177\/17579139221103189","article-title":"Is commissioning the enemy of co-production?","volume":"142","author":"Hart","year":"2022","journal-title":"Perspect. Public Health"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1080\/09540962.2019.1592905","article-title":"Co-commissioning of public services and outcomes in the UK: Bringing co-production into the strategic commissioning cycle","volume":"39","author":"Loeffler","year":"2019","journal-title":"Public Money Manag."},{"key":"ref_45","first-page":"733","article-title":"Effect of Home Visits by Nurses on the Physical and Psychosocial Health of Older Adults: A Systematic Review and Meta-Analysis","volume":"51","author":"Ergin","year":"2022","journal-title":"Iran. J. Public Health"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1177\/0898264318804946","article-title":"Impact of a Nurse-Led Health Promotion Intervention in an Aging Population: Results From a Quasi-Experimental Study on the \u201cCommunity Health Consultation Offices for Seniors\u201d","volume":"32","author":"Peters","year":"2020","journal-title":"J. Aging Health"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1186\/s12884-021-03642-7","article-title":"Maternal Health Care Utilization and the Obstetric Outcomes of Undocumented Women in Finland\u2014A Retrospective Register-Based Study","volume":"21","author":"Tasa","year":"2021","journal-title":"BMC Pregnancy Childbirth"},{"key":"ref_48","first-page":"41","article-title":"Indicator Madness: A Cautionary Reflection on the Use of Indicators in Healthcare","volume":"3","author":"Bowen","year":"2008","journal-title":"Healthc. Policy"}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/19\/22\/14819\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T01:14:16Z","timestamp":1760145256000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/19\/22\/14819"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,11,10]]},"references-count":48,"journal-issue":{"issue":"22","published-online":{"date-parts":[[2022,11]]}},"alternative-id":["ijerph192214819"],"URL":"https:\/\/doi.org\/10.3390\/ijerph192214819","relation":{},"ISSN":["1660-4601"],"issn-type":[{"type":"electronic","value":"1660-4601"}],"subject":[],"published":{"date-parts":[[2022,11,10]]}}}