Healthcare Equity and Commissioning: A Four-Year National Analysis of Portuguese Primary Healthcare Units.

Equal and adequate access to healthcare is one of the pillars of Portuguese health policy. Despite the controversy over commissioning processes' 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.