{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,28]],"date-time":"2026-02-28T04:31:38Z","timestamp":1772253098807,"version":"3.50.1"},"reference-count":45,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2022,12,24]],"date-time":"2022-12-24T00:00:00Z","timestamp":1671840000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Sustainability"],"abstract":"<jats:p>COVID-19 is a well-known respiratory disease that has spread worldwide since January 2020, causing many deaths and massive pressure on health systems. This pandemic\u2019s appearance compromised health service sustainability and quality as many procedures were postponed or canceled, with an expected increase of adverse events like nosocomial infections, in-hospital deaths, and the worsening of the patient\u2019s clinical status. For instance, the year 2020 featured an increase in undesirable results in Portugal: a rise of 10% in delayed first medical appointments, 0.02% in avoidable bloodstream infections, and more than 100 post-operative pulmonary embolisms and septicemia cases per 100,000 inpatients. Therefore, assessing whether the healthcare providers\u2019 performance has changed is paramount. In this case, we evaluated public hospitals in Portugal. To this end, we developed a network data envelopment analysis model relating to efficiency and effectiveness. We observed consistent drops in efficiency when the pandemic started, followed by a recovery to levels above the pre-pandemic ones. Regarding effectiveness, we observed a positive trend during the evaluated period. We conclude that, apart from the great resilience of public healthcare providers, the Portuguese state was unprepared for a pandemic like COVID-19, but still the actions taken (including massive vaccination) were beneficial.<\/jats:p>","DOI":"10.3390\/su15010294","type":"journal-article","created":{"date-parts":[[2022,12,27]],"date-time":"2022-12-27T04:35:43Z","timestamp":1672115743000},"page":"294","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":19,"title":["Evaluating Portuguese Public Hospitals Performance: Any Difference before and during COVID-19?"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6808-7769","authenticated-orcid":false,"given":"Alexandre Morais","family":"Nunes","sequence":"first","affiliation":[{"name":"Centre for Public Administration and Public Policies, Institute of Social and Political Sciences, Universidade de Lisboa, Rua Almerindo Lessa, 1300-663 Lisbon, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5418-9337","authenticated-orcid":false,"given":"Diogo Filipe da Cunha","family":"Ferreira","sequence":"additional","affiliation":[{"name":"Centre for Public Administration and Public Policies, Institute of Social and Political Sciences, Universidade de Lisboa, Rua Almerindo Lessa, 1300-663 Lisbon, Portugal"},{"name":"CERIS, Instituto Superior T\u00e9cnico, University of Lisbon, Av. Rovisco Pais 1, 1049-001 Lisbon, Portugal"}]}],"member":"1968","published-online":{"date-parts":[[2022,12,24]]},"reference":[{"key":"ref_1","first-page":"170","article-title":"Performance Measurement of Healthcare Systems in Europe","volume":"6","author":"Storto","year":"2017","journal-title":"J. Appl. Manag. Investig."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Markowicz, I., and Rudawska, I. (2021). Struggling with COVID-19\u2014A Framework for Assessing Health System Performance. Sustainability, 13.","DOI":"10.3390\/su132011146"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1016\/j.ijsu.2020.02.034","article-title":"World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19)","volume":"76","author":"Sohrabi","year":"2020","journal-title":"Int. J. Surg."},{"key":"ref_4","first-page":"19","article-title":"Understanding employees\u2019 responses to the COVID -19 pandemic: The attractiveness of healthcare jobs","volume":"40","author":"Alharbi","year":"2020","journal-title":"Glob. Bus. Organ. Excel."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"703","DOI":"10.20344\/amp.14675","article-title":"Revisiting Clinical Autopsies: Lessons to be Taken from the COVID-19 Pandemic","volume":"33","author":"Almeida","year":"2020","journal-title":"Acta Med. Port."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"103038","DOI":"10.1016\/j.cities.2020.103038","article-title":"Quality of life in the urban environment and primary health services for the elderly during the COVID-19 pandemic: An application to the city of Milan (Italy)","volume":"110","author":"Guida","year":"2021","journal-title":"Cities"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"185","DOI":"10.1016\/j.ijsu.2020.04.018","article-title":"The socio-economic implications of the coronavirus pandemic (COVID-19): A review","volume":"78","author":"Nicola","year":"2020","journal-title":"Int. J. Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1136\/leader-2020-000245","article-title":"The COVID-19 pandemic: Resilient organisational response to a low-chance, high-impact event","volume":"4","year":"2020","journal-title":"BMJ Lead."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"359","DOI":"10.1177\/0049085720936076","article-title":"COVID-19: Beyond Biological Dynamics","volume":"50","author":"Qadeer","year":"2020","journal-title":"Soc. Chang."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"eabe2424","DOI":"10.1126\/science.abe2424","article-title":"Transmission heterogeneities, kinetics, and controllability of SARS-CoV-2","volume":"371","author":"Sun","year":"2021","journal-title":"Science"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Correia, P., Mendes, I., Pereira, S., and Subtil, I. (2020). The Combat against COVID-19 in Portugal: How State Measures and Data Availability Reinforce Some Organizational Values and Contribute to the Sustainability of the National Health System. Sustainability, 12.","DOI":"10.3390\/su12187513"},{"key":"ref_12","unstructured":"Correia, T. (2020). The political management of COVID-19 in Portugal: Analytical insights for the international debate. SciELO, preprints."},{"key":"ref_13","unstructured":"Dire\u00e7\u00e3o Geral da Sa\u00fade (2022, September 02). Dados Epidemiol\u00f3gicos COVID, Available online: https:\/\/covid19estamoson.gov.pt\/estado-epidemiologico-covid19-portugal."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"146279","DOI":"10.1016\/j.scitotenv.2021.146279","article-title":"Investment in drinking water and sanitation infrastructure and its impact on waterborne diseases dissemination: The Brazilian case","volume":"779","author":"Ferreira","year":"2021","journal-title":"Sci. Total Environ."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"115169","DOI":"10.1016\/j.eswa.2021.115169","article-title":"Measuring the efficiency of the Portuguese public hospitals: A value modelled network data envelopment analysis with simulation","volume":"181","author":"Pereira","year":"2021","journal-title":"Expert Syst. Appl."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"196","DOI":"10.1002\/hpm.2613","article-title":"The health care reform in Portugal: Outcomes from both the New Public Management and the economic crisis","volume":"34","author":"Nunes","year":"2018","journal-title":"Int. J. Health Plan. Manag."},{"key":"ref_17","unstructured":"Harding, A., and Preker, A. (2000). Undestanding Organizational Reform: The Corporatization of Public Hospitals, World Bank."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1177\/0020731418822227","article-title":"Financial Crisis in Portugal: Effects in the Health Care Sector","volume":"49","author":"Nunes","year":"2019","journal-title":"Int. J. Health Serv."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"404","DOI":"10.1111\/1467-8500.12263","article-title":"Justice, Efficiency, and the New Public Management","volume":"77","author":"Volacu","year":"2017","journal-title":"Aust. J. Public Adm."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Abrate, G., Boffa, F., Erbetta, F., and Vannoni, D. (2018). Voters\u2019 Information, Corruption, and the Efficiency of Local Public Services. Sustainability, 10.","DOI":"10.3390\/su10124775"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"2571","DOI":"10.1002\/jcop.22435","article-title":"Beyond new public management: Empowering community-based organisations","volume":"48","author":"Mailloux","year":"2020","journal-title":"J. Community Psychol."},{"key":"ref_22","unstructured":"Nunes, A. (2016). Reformas na Gest\u00e3o Hospitalar: An\u00e1lise dos efeitos da empresarializa\u00e7\u00e3o. [Ph.D. Thesis, Health Administration at University of Lisbon]."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1111\/j.1467-9299.1991.tb00779.x","article-title":"A public management for all seasons?","volume":"69","author":"Hood","year":"1991","journal-title":"Public Adm."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"537","DOI":"10.1017\/S0047279406000079","article-title":"Extending Choice in English Health Care: The Implications of the Economic Evidence","volume":"35","author":"Propper","year":"2006","journal-title":"J. Soc. Policy"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"537","DOI":"10.1016\/S0167-6296(97)00042-8","article-title":"Creaming, skimping and dumping: Provider competition on the intensive and extensive margins","volume":"17","author":"Ellis","year":"1998","journal-title":"J. Health Econ."},{"key":"ref_26","unstructured":"Instituto Nacional de Estat\u00edstica (2022, October 06). Persons Employed (No.) in Public Hospitals. Available online: https:\/\/www.ine.pt\/xportal\/xmain?xpid=INE&xpgid=ine_indicadores&indOcorrCod=0008117&contexto=bd&selTab=tab2&fbclid=IwAR1GNZcJO-nIUpjczks-EgPwKTjzebgXxWl93TxxpBdUc2GlkrbGKMZdXsc."},{"key":"ref_27","unstructured":"de Contas, T. (2020). COVID-19\u2014Impacto na Atividade e no Acesso ao SNS. Relat\u00f3rio n.\u00ba 5\/2020\u20142.\u00ba sec\u00e7\u00e3o, Tribunal de Contas."},{"key":"ref_28","unstructured":"Movimento Sa\u00fade em Dia (2022, October 06). Indicadores de Acesso. Available online: https:\/\/www.saudeemdia.pt\/?p=indicadores."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1007\/s10198-014-0574-8","article-title":"Did the corporatization of Portuguese hospitals significantly change their productivity?","volume":"16","author":"Ferreira","year":"2014","journal-title":"Eur. J. Health Econ."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1007\/s10729-018-9436-8","article-title":"The use of Data Envelopment Analysis (DEA) in healthcare with a focus on hospitals","volume":"22","author":"Kohl","year":"2019","journal-title":"Health Care Manag. Sci."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"367","DOI":"10.1007\/s10198-009-0198-6","article-title":"The challenge of corporatisation: The experience of Portuguese public hospitals","volume":"11","author":"Rego","year":"2010","journal-title":"Eur. J. Health Econ."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1487","DOI":"10.1111\/jgs.17642","article-title":"Physicians\u2019 perspectives of prognosis and goals of care discussions after hip fracture","volume":"70","author":"Murthy","year":"2022","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"166","DOI":"10.2307\/3348969","article-title":"Evaluating the quality of medical care","volume":"44","author":"Donabedian","year":"1966","journal-title":"Milbank Meml. Fund Q."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"425","DOI":"10.1007\/s41999-021-00600-6","article-title":"Impact of COVID-19 on hip fracture care in Ireland: Findings from the Irish Hip Fracture Database","volume":"13","author":"Brent","year":"2022","journal-title":"Eur. Geriatr. Med."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"727","DOI":"10.1007\/s00238-020-01737-6","article-title":"Perioral pressure ulcers in patients with COVID-19 requiring invasive mechanical ventilation","volume":"43","author":"Sleiwah","year":"2020","journal-title":"Eur. J. Plast. Surg."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1186\/s13756-020-00851-1","article-title":"Central venous catheter-related bloodstream infection and colonization: The impact of insertion site and distribution of multidrug-resistant pathogens","volume":"9","author":"Pitiriga","year":"2020","journal-title":"Antimicrob. Resist. Infect. Control."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"149","DOI":"10.1016\/j.jhin.2021.09.020","article-title":"Increase in the frequency of catheter-related bloodstream infections during the COVID-19 pandemic: A plea for control","volume":"119","author":"Carrillo","year":"2022","journal-title":"J. Hosp. Infect."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1007\/s12028-015-0221-y","article-title":"Prophylaxis of Venous Thrombosis in Neurocritical Care Patients: An Evidence-Based Guideline: A Statement for Healthcare Professionals from the Neurocritical Care Society","volume":"24","author":"Nyquist","year":"2016","journal-title":"Neurocrit. Care"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"355","DOI":"10.1007\/s12028-018-0614-9","article-title":"Venous Thromboembolism Prophylaxis in Neurocritical Care Patients: Are Current Practices, Best Practices?","volume":"30","author":"Sauro","year":"2019","journal-title":"Neurocrit. Care"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1995","DOI":"10.1111\/jth.14888","article-title":"Incidence of venous thromboembolism in hospitalized patients with COVID-19","volume":"18","author":"Middeldorp","year":"2020","journal-title":"J. Thromb. Haemost."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"290","DOI":"10.1016\/j.jgar.2020.10.004","article-title":"Incidence of bacterial and fungal bloodstream infections in COVID-19 patients in intensive care: An alarming \u201ccollateral effect\u201d","volume":"23","author":"Cataldo","year":"2020","journal-title":"J. Glob. Antimicrob. Resist."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"e31","DOI":"10.1097\/CCM.0000000000004748","article-title":"Unexpectedly High Frequency of Enterococcal Bloodstream Infections in Coronavirus Disease 2019 Patients Admitted to an Italian ICU: An Observational Study","volume":"49","author":"Bonazzetti","year":"2021","journal-title":"Crit. Care Med."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1007\/s10729-014-9286-y","article-title":"Should inpatients be adjusted by their complexity and severity for efficiency assessment? Evidence from Portugal","volume":"19","author":"Ferreira","year":"2016","journal-title":"Health Care Manag. Sci."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1057","DOI":"10.1002\/hec.1388","article-title":"Cost and technical efficiency of German hospitals: Does ownership matter?","volume":"17","author":"Herr","year":"2008","journal-title":"Health Econ."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1252","DOI":"10.1002\/hpm.3407","article-title":"Vertical integration in healthcare: What does literature say about improvements on quality, access, efficiency, and costs containment?","volume":"37","author":"Amado","year":"2022","journal-title":"Int. J. Health Plan. Manag."}],"container-title":["Sustainability"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2071-1050\/15\/1\/294\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T01:50:16Z","timestamp":1760147416000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2071-1050\/15\/1\/294"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,12,24]]},"references-count":45,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2023,1]]}},"alternative-id":["su15010294"],"URL":"https:\/\/doi.org\/10.3390\/su15010294","relation":{"has-preprint":[{"id-type":"doi","id":"10.20944\/preprints202210.0201.v1","asserted-by":"object"}]},"ISSN":["2071-1050"],"issn-type":[{"value":"2071-1050","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,12,24]]}}}