The context for supply and demand of public online services in Portugal

Portugal has been a Parliamentary Republic since 1974, and joined the European Community in 1986. The country is administratively divided into two autonomous regions (Azores, Madeira) and eighteen districts with 308 Municipalities. Both central government and local authorities (municipalities) are responsible for delivering public services; responsibilities may differ depending on the type of service. However, as is the case for most EU Member States, the main driver for eGovernment initiatives is the central government.

Key figures about Portugal[1]

	Portugal	Ø EU15	Ø EU25
Old age dependency ratio	24.9	25.5	24.5
Population density	112.1	119.8	116.3
GDP per head	72.7	108.6	100
GDP growth - 5 year average	1.13%	1.85%	1.92%
Unemployment rate	6.7%	8.1%	9.0%
Inequality index	36	30	29

According to the Portuguese government, in 2004 the country's population was 10,536 million. The population has been growing steadily during the last years, leading to higher gains than on average in the EU15[2].

With regard to the country's economy, soon after joining the European Union in 1986 Portugal entered a phase of impressive economic development, surpassing many of the more economically advanced EU partners. However, during the years 2001 to 2004 economic growth stalled, resulting in GDP growth rates below the European average. More significantly, the poor educational system is considered to be a structural cause of weak long-term growth and productivity prospects. On the positive side is the unemployment rate, which is considerably lower in Portugal than in most other EU Member States.

Portugal's performance within the Information Society is modest, meaning that greater efforts are necessary to develop its infrastructure, and also to involve more citizens in the use of ICTs. It is indicative of the situation that Portugal has only half as many households with Internet access than the EU average, and that digital disparities (measured by the digital divide index) are considerably bigger than elsewhere.

Broadband penetration in the country is not insignificant, but still more efforts will be needed to reach the 8% target defined by the European Commission. An encouraging fact is that both consumers and the State invest in new technologies: ICT expenditure in Portugal, expressed as a percentage of GDP, is significantly higher than for the EU25 as a whole.

Information Society indicators[3]

	Portugal	Ø EU15	Ø EU25
Households with Internet access	26%	45%	42%
Broadband penetration	6.4%	7.6%	6.5%
Price for Internet use basket	73.25	49.57	48.35
ICT expenditure as percentage of GDP	4.6%	3.2%	2.6%
Digital Divide Index	27.3	53.0	50.1

Portugal's performance on the UN Telecom Index[4]

eHealth in Portugal

In Portugal the majority of the technical means to support eHealth and telephone-based healthcare services are developed by private companies. On its part, the State has adopted a centralised approach to eHealth by designing a sole eHealth Network. The government's macro-objective is to equip all of the National Health System's units with ICTs, and to a large extent, this goal has been accomplished considering that by November 2003, every hospital and primary healthcare centre had an Internet connection.

Key figures about the Portuguese Health System [5]

	Portugal	Ø EU15	Ø EU25
Percentage satisfied with own health	69.1%	82.5%	79.8%
Prevalence of long-term illness	15.5%	13.8%	20.0%
Doctors per 100.000 inhabitants	265	233	251
Health expenditure as percentage of GDP	6.6%	7.4%	7.3%

eHealth in Portugal is supplied by a mix of private and public providers. In particular, the major eHealth portals in the country are:

Direcção-Geral de Saúde (General-Directorate of Health, www.dgsaude.pt): This governmental portal offers users the possibility to have access to general information concerning:

• The national health system, namely hospitals and health care public centres, obligations and rights of patients, patients guide, national health plan, etc.;
• Healthcare, health diagnosis, diseases and health prevention;
• Environmental threats for public health;
• Nutrition and fitness.

In addition, users can also have access to national health statistics, a virtual library and a database with information about national and international governmental institutions, international associations, periodic publications and other web links. A site search on key words is also available for users. Moreover, a registration area, with a formulary, is available for local health authorities, in order for them to be informed on particular situations, namely prenatal mortality and heat waves.

Netmed - público (www.netmed-publico.pt): This public portal, owned by a private company - netsaúde, sa: Gestão e Prestação de Serviços na Área da Saúde via Internet (health and service delivery in health throughout the use of Internet) - was created in 2001. Its main aim is to create a platform of common interests and understanding between all health care professionals and citizens. Within this portal it is possible to find:

• Information on medicines, pharmacies, health entities and doctors by name, speciality or location;
• General healthcare information, namely encyclopaedia of diseases, complementary means of diagnosis and therapeutics, and ABC of Good Health;
• Health Thesaurus;
• Travellers Encyclopaedia - provides information about international public health concerns;
• Health news;
• Links to Patients Association;
• Queries on general national health concerns and related statistical results;
• Search on key words.

In addition, this portal allows users to have access to another site - net-Médico - exclusively directed to medical professionals, created by the same company.

Viva Saudável - www.vivasaudavel.pt: The Viva Saudável is a private portal aiming at providing scientific information concerning healthcare, health prevention and health diagnosis to all citizens. The quality of information available online is guaranteed by a professional team of doctors, specialists, health professionals and communication professionals. This portal allows users to access a set of general information concerning:

• Diseases, medicines, health advice, medical exams and medical specialities, all provided by online encyclopaedias;
• Life events, from birth to old age, namely through articles, discussion groups and FAQ's;
• Fitness, nutrition, sexuality and beauty;
• Actual news on health;
• Pharmacies;
• Health Events;
• Links to other entities, such as Patients Associations, Health Higher Education Institutions; Health Professional Associations, etc.

Internet Use for Searching Health Information[6]

In addition, Viva Saudável provides two services to users. The first is an interactive health service, in which users (after registration) can ask any health questions, discuss any health topic, or test their own health. The second is the e-emergency service, in which users can find information on how to deal with burns, asphyxia, poisoning, trauma, etc., and also obtain several contact telephone numbers of a set of specialised institutions.

With regards to information services about health, two examples have received much public attention recently: Longe e Melhor, a private website operated by Pentafarma - Sociedade Técnico-Medicial S.A. with the purpose of providing information on cardio-vascular disease prevention; and Sexualidades, a public website aiming at the diffusion of and sensitisation for sex education and sexuality concerns throughout the national population.

Citizens who wish to be informed about available health services can turn to the website of Saúde Global (www.saudeglobal.com). This was created by a private company, ENTERSITE - Gestão e Manutenção de Páginas na Internet, S.A., aiming at the creation of an eHealth discussion and advertising space. The site provides the possibility for doctors and health professionals to have access to actual information concerning new technologies, equipment, medicines and products. They can also participate in debates and forums, and create individual professional sites. What's more, the site allows private companies to create electronic catalogues and advertise their products. The website also disposes a set of databases, providing information about location and phone contacts, namely related to doctors, hospitals, pharmacies, health centres, nursing centres, medical clinics, analysis and diagnosis centres, health technicians, health services, on-line sales, therapy centres and pharmaceutical laboratories. Within each directory, it is possible to do a search by locality.

Two more sites, developed by private companies, encompass multiple functions. Medis is a health insurance company, associated to a private bank - Banco Comercial Português. The main aim of Medis System is to provide its clients a credible network of doctors, clinics and hospitals, and financial and information facilities concerning healthcare and other health services. This service provides two kinds of services: a public information service, directed at the general population, and a restricted service, just accessible by Medis clients and health professionals (health suppliers). Concerning public information, the site provides general information about insurance conditions and advantages with respect to the Medis system. Also, the Medis Guide provides a list of health institutions, doctors and complementary means of diagnosis associated with the System, which can be searched for; search can be made by location, medical speciality and health service. On the website, users can also find general healthcare information about life stages, medical exams, women and men's health, medicines and diseases as well as employment opportunities directed at nurses. With respect to the restricted services, these are only accessible by Medis clients or health professionals associated with Medis network. This restricted access is made through a login and a password provided by the company, which allows access to private information, such as consulting history, costs, insurance policy, etc. No medical practice (consultations, medical diagnosis, medicine prescription, etc) is allowed through the site.

SIM-SERVIÇO INTERMÉDICO (www.simsaude.com) is a private company that renders services in the area of healthcare. Its mission is to provide quality healthcare services to its clients, through a network of doctors, clinics, hospitals and medical labs.

The information provided in the web site is structured in 5 different domains: (1) Public domain: provides general information about the company and about the health services available; (2) Companies: general information directed to the companies, namely concerning labour medicine and labour safety and health. It also provides an information desk, through which companies can ask about specific information; (3) Services: general description of the health packages of services available though the company; (4) Health suppliers: restricted service to health institutions and professionals; (5) Sim Saude Network - list of doctors, clinics, hospitals and labs available within SIM SAUDE Network. The search can be made by geographical location and medical speciality.

General Practitioners with Websites[7]

With regards to the online presence of health institutions and professionals, although one can find a few examples of advanced websites, on the whole, online representation of health actors poses a great challenge for the future.

In terms of health institutions, generally, websites that are developed by public institutions (hospitals, clinics, etc.) simply provide information, which mainly concerns the organisation of the institution, rather than the patients' dimension.

However, aesthetics medicine may be an exception. It is possible to observe that this kind of service provides specific and detailed information about surgical and other aesthetics treatments in order to attract patients' attention. An example can be the Clínica de Cirurgia Plástica e Reconstrutiva - Plastic Surgery and Reconstructive Clinic (www.ccpr.pt). This is a private clinic oriented to surgical and non-surgical aesthetic treatments. The website provides detailed information on both kinds of treatment, as well as general information about the structure and organisation of the services (treatment units, doctors, technological equipment). The site also provides the opportunity to establish an online contact by filling out a small form, in which users can place doubts and questions.

In terms of health professionals, a 2002 Eurobarometer survey showed that 26% of Portuguese doctors have their own website, which is above average for old European countries, but Portugal is still half way down the list of leading countries in the field.

Nevertheless, a common feature of all available eHealth services is that they mainly consist of medical information and basic health services. Interaction between doctors and patients through the WWW is prohibited by law in Portugal: According to article 7, number 1 of Law 67/98, the analysis and diffusion of health personal data is not allowed. The law, however, makes an exception in cases when the use of data concerns preventative medicine, medical diagnosis or medical treatment. In these exceptional cases, any personal information may only be available among professionals, under professional confidentiality.

For the same reasons, there are no online pharmacies in Portugal, since the online distribution of pharmaceutical products is not allowed.

On the other hand, the use of the telephone to obtain medical information and advice is quite widespread among the Portuguese population. In Portugal there are a set of telephone lines, which provide medical information, advice and medical guidance services. These telephone lines encompass diversified support areas, such as paediatric information, medicines, general public health and poisonings. These are confidential consultations provided by health professionals, namely nurses, and most of them are free of charge. This telephone aid is a good starting point for advice, but it does not replace (and should not replace) a medical consultation and diagnosis.

Some examples are:

• Linha Intoxicações (poisonings line): it provides first basic procedures and information in case of domestic and occupational exposure to toxic substrances (+351 21 7950143);
• Sáude 24 (Health 24): is a telephony service oriented to health problems of children under 14. It is a 24 hour service, which makes the first such medical advice line(+351 808242400);
• Linha Saúde Pública (Public health line): it provides general information about conjunctural epidemics that may be eminent in Portugal (+351 808211311).
• Linha Infarmed Medicamentos (Medicines Line): the responsibility of the National Pharmaceutical Institute, this telephony service provides information about generic products (+351 800 222444).

Overall, there are no specific telephone lines through which patients can make a medical consultation with their own doctors, or other health institutions. There are cases when private or family doctors give their own patients their private telephone number for specific consultation or explanation, but this is an informal and non-official way of consultation. Most of the cases stated above are Aid Telephone lines that can be included in the category of more widely dedicated phone-based (triage) services.

There are no specific policies/regulations with respect to online or telephone-based medical consultations that encourage or discourage their supply and/or usage. Nonetheless, according to the Advisor of the Secretary of State for Health, this is a subject that is already under consideration.

The development of eHealth services is not presently influenced by any specific policy framework, nor is it supported by particular political measures and initiatives enhancing the use of eHealth services. However, the National Action Plan for the Information Society (PASI), approved in June 2003, sets eHealth as a national priority. The main political aim is to place the Citizen in the centre of health priorities. Within this Action Plan, the eHealth policy is divided into three action lines: eHealth services, health information network, and patient cards. Some of the most important related projects are the development of a Health reception portal, the generalisation of electronic clinical processes, namely complementary diagnosis means, the improvement of the health information network, and the development of a Patient identity card.

Apart from these political intentions, it is also possible to identify some pilot academic initiatives regarding the development of eHealth services. One of the most relevant examples is the development of RTS - Telematic Health Network, a pilot initiative directed by the University of Aveiro and Hospital Infante D. Pedro, Aveiro.

In the spotlight: Netmed - público

User orientation in eHealth services

Overall, it could be stated that Portuguese eHealth services take little or no account of user needs, and this is a reflection of the fact that the State eHealth policy framework describes technical achievements, but makes no mention of the end-users. This is a major barrier to the uptake of eHealth services by citizens who at present appear reluctant to use them and still prefer the traditional doctor-patient interaction. Another hurdle on the users' side is the low educational level, and the lack of awareness of eHealth services.

From the Institutions' point of view, the main barriers result mainly from two aspects; first, the still existing paucity of basic technical means (e.g. electronic equipment), human and financial resources; and second, the lack of awareness of eHealth potentiality - health professionals and the institutions administration boards still exhibit some scepticism in using these services from the medical perspective (for several reasons, some of which have already been explained; another reason indicated here is related to the budget needed to overcome potential security problems that may be frequently encountered). Nonetheless, they regard the use of ICTs as a good way to diminish the existing administrative bureaucracy.

But even health professionals remain sceptical towards the adoption of ICTs in health, and the potential practice of medicine through them. Often they have expressed concerns about the type of information that should be made available online. In particular, they argue that patients do not have the expertise to evaluate a medical diagnosis, thus they should not have access to this type of information. Moreover, although they acknowledge that eHealth services may prove to be extremely useful in diminishing administrative bureaucracy, they do not support the practice of medicine through eServices.

Currently, the main thrust for the development and supply of eHealth services comes from the private sector due to the financial benefits companies hope to receive. The public sector still lags behind in developing these kinds of services due to the high cost their development entails. However, the work that Universities and Research Units are developing on some eHealth areas must be equally highlighted.

In a European Foundation research (see chart) the Portuguese were the least satisfied, of the European population, with their national healthcare system. In fact,, due to the National Health Care System's characteristics, such as lengthy waiting lists, excessive bureaucracy, etc., those who can afford it prefer private clinics instead of public hospitals. In these cases, people may use eHealth services to search for doctors or specialised clinics, but most of the time they have private insurance and consequently visit the doctors associated with their insurance company. Thus, in response to what appears to be a pressing demand to reform the public health system, eHealth services could be introduced as part of a new, enhanced, versatile and patient-oriented health scheme.

So to sum up, it seems that neither are the existing eHealth services designed with user needs in mind, nor do the actual supply of eHealth services cover the spectrum of eHealth related interests of the public/patients. In fact, as in many other ICT services, the logic prevails that supply induces demand, and under this pretext no significant processes of decision-making support are elaborated, such as the development of social and economic studies concerning patient/consumer needs.

Satisfaction with National Healthcare System[8]

eUser - the Project

The eUser study is funded by the European Commission's IST (Information Society Technology) programme. eUser is a major research and support project which has set out to provide solid evidence as to users' real needs regarding eGovernment, eHealth and eLearning offers, as well as providing data about their attitudes and the uptake levels of current public online services. The project supports the IST programme to achieve its key objectives of putting the user and his/her needs at the centre of IST developments. It provides empirical information on key public eServices domains -eGovernment, eHealth, eLearning - identified as priorities by the European Council, and assesses the demand/supply match in these fields.

The eUser Approach

To achieve its objectives, eUser addresses both generic user-related issues and domain-specific topics, and develops a globally accessible repository of evidence-based knowledge, methods and best practice examples. It pursues an extensive programme of active knowledge translation, transfer and dissemination supported by sophisticated online knowledge dissemination tools. The knowledge base will consolidate both existing knowledge and approaches, and novel data generated by the project through representative population surveys (demand side) in old and new Member States, and through comparative analyses of readiness to address user aspects of public eServices in each Member State (supply side).

The project is designed in two phases. Phase I - the preparatory phase - has developed a conceptual framework that systematically identifies and cross-references user issues and service characteristics in relation to online public services. An EU-wide population survey regarding the needs, experiences and requirements of both current and potential users of online public services has been carried out in early 2005. Concerning the supply side, information from national public sector environments has been collected, about the degree to which the European public sector pays sufficient attention to user-orientation of online services. Good practice examples regarding user-appropriate online public service provisions are being identified and described.

All these results build the basis and provide content for the eUser interactive online knowledge base and support service which is being set up as an online observatory on user issues. This constitutes the basis for active support services on user-centred topics which are being made available inside and outside the IST programme.

eUser Country Briefs

This document has been prepared by FORTH based on information provided by a National Correspondent (Gonçalo de Sousa Santinha, University of Aveiro, CEIDET) as well as secondary data sources such as Eurostat and other Commission Services.

25 eUser eHealth Country Briefs are available in a common format, one for each member of the enlarged European Union. You can access and download these documents in PDF format (for free) from our website.

More information

Check our results and achievements on: www.euser-eu.org. If you wish to be provided with more details, or to receive news and updates, please contact us at: eUser@empirica.com or get in touch with any of the project partners listed below.

empirica Gesellschaft für Kommunikations- und Technologieforschung mbH (Project Co-ordinator) Oxfordstr. 2, 53111 Bonn, Germany, Tel.: +49 228 985 30 0, www.empirica.com

Danish Technological Institute Center for Competence and IT Kongsvang Allé 29, Aarhus, Denmark, Tel.: +45 72201417, www.teknologisk.dk

Foundation for Research and Technology - Hellas Institute of Computer Science P.O. Box 1385, Heraklion, Crete, GR - 71110 Greece, Tel: +30-2810-391741, www.ics.forth.gr

Work Research Centre Ltd. 1 Greenlea Drive, Terenure, Dublin 6W, Ireland, Tel.: +353 1 492 7042, www.wrc-research.ie

University of British Columbia, Vancouver, BC, Canada #105 - 2194 Health Sciences Mall, Vancouver, B.C., Canada, Tel.: +1 6 04 6 39 46 68 www.cme.med.ubc.ca

National Research Council Canada, Saint John, New Brunswick 127 Carleton Street, Saint John, New Brunswick, Canada, E2L 2Z6, Tel: +1 5 06 6 35 06 33, www.iit-iti.nrc-cnrc.gc.ca

Notes About the Data Sources Used in this Document

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