Abstract

This study aims to evaluate the quality of the Portuguese Government’s action in the health sector during Troika’s intervention period (2011-2015), taking as criterion the concern with the application of Good Governance principles, in terms of degree and diversity. The intention is to understand the extent to which the public action promoted by the Ministry of Health has developed seeking to contribute to the strengthening of Good Governance practices. Fifty measures of the Ministry of Health, distributed by nine intervention areas, were analyzed, based on documental analysis, supported on the law and on other official documents. The principles of Good Governance that demonstrate a more transversal concern are clearly that of “transparency” and of “effectiveness/efficiency”, present in eight of the nine intervention areas. The concern with “orientation to consensus” is essentially present in the measures classified as Agreements, “independence” in the Ethics area, the “strengthening of the rule of Law” in the Control area and “equity/inclusion” in the area of the Citizen in the Centre of the NHS.

Key words
Good governance; Health; Portugal; Troika

Introduction

At the beginning of 2011, Portugal, in a situation of great financial weakness, found itself constrained to request support to the International Monetary Fund (IMF), to the European Commission and to the European Central Bank (ECB), a set of funding bodies which was popularly known as Troika. The Memorandum of Understanding (MoU) ¹1 Portugal, XIX Governo Constitucional. Tradução do conteúdo do Memorando de Entendimento sobre as Condicionalidades de Política Económica. Lisboa: Presidência do Conselho de Ministros; 2011[acessado 2018 Maio 2]. Available from: https://www.portugal.gov.pt/media/371372/mou_pt_20110517.pdf
https://www.portugal.gov.pt/media/371372... , signed on 17 May 2011, imposed several structural reforms which, on the health sector, implied interventions in three priority areas: a) focus on the efficiency and effectiveness of the health system; b) expenditure control and more rational use of resources; c) cost reduction in the hospitals.

According to the statements of the President of the Health Regulatory Authority’s Board of Directors²2 Simões J. O Memorando de entendimento entre UE/ BCE/FMI e Portugal. Intervenção na Conferência O Sector da Saúde. Como executar as medidas?. Lisboa: INA; 2001., the MoU envisaged a reduction of the public expenditure with medicines in 1.25% of the GDP until the end of 2012 (about 516 million euros) and in about 1% of the GDP in 2013 (approximately 431 million euros). The acquisition of complementary diagnosis and therapeutic means by private entities would suffer a 10% decrease in 2011 and more 10% in 2012; furthermore, the competition between private providers should be reinforced and a periodical review of the prices paid to them should be established. The MoU also envisaged the reduction, in one third, of the costs with patient transport.

At a hospital level, there was a target for a decrease, in the operational costs, of 100 million euros in 2011 and other 100 million euros in 2012, given that approximately 50% of the costs concerned staff costs. These amounts did not include the values of debts to suppliers.

The MoU stipulated the creation of a schedule for the settlement of all arrear payments (over 90 days) and the introduction of standardized control procedures to prevent the resurgence of such situations. At the end of 2010, the average term for the payments to suppliers was 78 days for the hospitals of the public administration sector and 212 days for the public business sector.

Regarding the budget of the public subsystems, the MoU established a 30% reduction in 2012 and an additional reduction of 20% in 2012. It also set that, in 2016, the subsystems would have to be self-funded.

Moreover, the MoU envisaged the review of the categories of exemption from user charges, positively differentiating the primary health care, through lower charges, in detriment of the specialty appointments and emergency episodes, automatically indexing them to inflation. It also indicated a two thirds reduction of the health expenditure’s tax deductions.

The reorganization and rationalisation of the hospital network were one of the measures provided for in the MoU, with the intent of an additional reduction in the operational costs of, at least, 5% in 2013, through the specialization, services concentration and joint management of units. It also envisaged a more efficient use of the health professions, mainly regarding the nursing career, and the adoption, by all of the staff, of a stricter control of the work hours, in order to achieve, at least, a 10% reduction of the expenditure with overtime hours in 2012 and additional 10% in 2013.

In this framework of severe budgetary restrictions and great external constraints, imposed by the funding bodies through the targets established in the MoU, the action of the 19^th Constitutional Government was developed. In our view, the significant impact observed on the health sector makes it relevant to assess the governance action regarding the concern with the strengthening of Good Governance practices (principles) in this key sector for society. Therefore, this study aims to answer the question: Does the Portuguese Government’s action in the health sector between 2011 and 2015 (Troika’s intervention period) show a concern with the application of the Good Governance principles? The aim is to assess the public action’s contribution promoted by the Ministry of Health for the strengthening of the Good Governance practices, given its principles, in degree and diversity.

Theoretical foundations

Globalization transformed the public action stage. The States must answer to complex and frequently diffuse problems, in a space no longer confined to the borders that traditionally delimited their sovereignty. They are aware of growing interdependency levels on the search for solutions for shared problems: between the States and the supra and infra-state entities, between the public and the private, between the center and the periphery.

Governance is more than a trendy expression, it is the acknowledgement that the last decades brought transformations regarding how governance is developed, boosted by alterations in the framework in which the States act.

Governance is not defined in a cohesive and consensual paradigm³3 Bilhim J. Ciência da Administração. Lisboa: Instituto Superior de Ciências Sociais e Políticas; 2013.. It is the result of the assumption of an evolving reality, which means changes on the exercise of the State’s role and its interaction with civil society. Likewise, it is not a process of standardizing transformation as the institutions, in each country, end up adopting the governance structures and mechanisms best suited for their choices, beliefs and traditions. This implies the inexistence of equal reform exercises. In practice, the decision-makers select the key-ideas, the values, the objectives and the measures deemed as closer to their intention, as well as to the political and cultural traditions of the populations and territories, although this selection is based on reform doctrines disclosed by international bodies, as well as by academic and professional means of Public Administration.

The last four decades were essentially marked by two reform doctrines - the New Public Management (NPM) and the Public Governance - which oppose the governance paradigm dominant for almost a century: the bureaucratic model, also known as professional Weberian model. In the first half of these four decades, the innovation practices were inspired by NPM; however, the last twenty years have led to the triumph of governance, a magical concept, according to Pollitt e Hupe⁴4 Pollitt C, Hupe P. Talking about Government. Public Manage Rev 2011; 13(5):641-658.’s classification, as it is broad and ambiguous, modern and progressive, consensual and widely used by the pertinent communities.

The word “governance” has its etymological origin in the Greek kybernan, which was translated to Latin as gubernare, meaning to pilot, guide or drive⁵5 Levi-Faur D. From 'Big-Government' to 'Big Governance'? In: Stephen PO, organizador. The New Pubic Governance? Emerging perspectives on the theory and practice of public governance. Londres: Routledge; 2012. p. 2-18.^,66 Hughes O. Does Governance Exist? In: Stephen PO, organizador. The New Pubic Governance? Emerging perspectives on the theory and practice of public governance. Londres: Routledge; 2010. p. 87-104. Due to its popularity, it has been used in several meanings and contexts, inhibiting a precise definition. Nevertheless, we can find some approaches to its delimitation.

One of the reference texts on governance is by Rhodes⁷7 Rhodes RAW. The New Governance: Governing Without Government. Polit Stud 1996; XLIV:652-667. who, in the mid-nineties, outlines six common uses for governance: minimum state, corporate governance, new public management, good governance, socio-cybernetic system and, finally, self-organized networks. While governance as a minimum state has suffered from a lower accession, as the awareness of the State’s need to assume the role of the system’s regulator⁸8 Pierre J. Governance and Institutional Flexibility. In: Levi-Faur D, organizador. Oxford Handbook of Governance. Oxford: Oxford University Press; 2012. p. 186-200. grows, the other meanings started to mark the reform plan⁸8 Pierre J. Governance and Institutional Flexibility. In: Levi-Faur D, organizador. Oxford Handbook of Governance. Oxford: Oxford University Press; 2012. p. 186-200.. This paper highlights the concept of Governance as Good Governance, that is, seek that governance meets the society needs, making good use of the public resources and respecting a set of values such as justice, equity, impartiality, legality, legitimacy and transparency.

In short, we can affirm that Governance, similarly to NPM, may be regarded as the answer to the society’s growing complexity and to the difficulty shown by the classic social State on dealing with this complexity⁹9 Klijn EH. New Public Management and Governance: A Comparison. In: Stephen PO, organizador. The New Pubic Governance? Emerging perspectives on the theory and practice of public governance. Londres: Routledge; 2012. p. 201-214.. It aims to redefine the structures, processes and roles of the public sector, so that Public Administration can be a catalyst of democratic governance, going beyond the search for a greater efficiency, cost reduction and improvement of the quality of the public services provision, which are the basis of NPM. Through the prism of networks governance and the focus on the interorganizational dimension, implicit in the public policies process and on the provision of public services, the instruments to use reinforce the coordination of the several involved players, using their knowledge to improve the quality in the services provision and in the preparation and implementation of public policies, as well as to increase the legitimacy of the decisions made, through co-creation, co-production and co-accountability processes.

The current governance framework is the result of the influence of the Public Governance paradigm, together with the managing perspective of NPM, based on the virtuous inheritance of the Weberian model. If the face the reform paradigms as part of a continuum of juxtapositions in which, according to the context, there is a simultaneous presence, although in variable proportions, of different paradigms, we tend to understand the need of the system’s good governance to know how to deal with the hybrid administrative practice and, consequently, with the legacies of previous paradigms.

Methodological procedures

The assessment of the governance’s quality may take two possible analysis paths which, although complementary, correspond to clearly distinct approaches. The first and most frequent is the assessment of the outcomes’ evolution. The second and less common corresponds to the assessment of the adoption and application of the Good Governance principles by the stakeholders on the design and implementation of public policies¹⁰10 Bovaird T, Löffler E. Evaluating the quality of public governance: indicators, models and methodologies Int Rev Adm Sci 2003; 69(3):313-328..

This study opted for the second approach, seeking to assess the quality of the governance in Health, in the Troika’s intervention period (2011-2015), aiming to assess if the public action promoted by the Ministry of Health mirrors a compromise towards the strengthening of the Good Governance practices, evident on the concern with the promotion of its principles, considered in degree and diversity terms. Therefore, it aimed to answer the following question: Does the Portuguese Government’s action in the health sector between 2011 and 2015 (Troika’s intervention period) show a concern with the application of the Good Governance principles? It intends to understand if it is possible to identify, in the public action promoted by the Ministry of Health, a concern with the governance quality, materialized on the adoption and promotion of the Good Governance principles observed in the research carried out. The key question previously indicated was divided in four research questions to which the study tried to answer:

What are the Good Governance principles that can be identified in the Ministry of Health’s public action?

What is the global incidence degree of the concern with the promotion of each of the Good Governance principles, evident on the Ministry of Health’s public action?

Is the relative weight of the concern with the promotion of each of the Good Governance principles identical in all areas of intervention of the Ministry of Health?

Does the Ministry of Health’s public action show a similar level of transversality of the concern with the promotion of each of the Good Governance principles?

Good Governance Principles considered

The concept of Good Governance appears, for the first time, in 1989 in a report by the World Bank¹¹11 Banco Mundial. Sub-Saharan Africa: From Crisis to Sustainable Growth. Washington D.C: World Bank; 1989., within the scope of support to the development, as a way to answer to the need to assess the governance quality of the States which applied to support programmes. This subject is emphasized on a 1992 report called “Governance and Development”. It includes the first definition of governance as “the way the power is exercised on the management of a country’s economic and social resources, for the development”¹²12 Banco Mundial. Governance and Development. Washington D.C: World Bank; 1992. p. 1-3. and approaches four governance areas: the management of public sector; the accountability; the legal framework for the development; and the information and transparency. Still within the scope of the support to the development agenda, several other definitions appeared, by funding bodies, such as the United Nations¹³13 United Nations Development Programme (UNDP). Governance for Sustainable Human Development: A UNDP Policy Document. New York: UNDP; 1997.^,1414 United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP). What is Good Governance? UNESCAP; 2009 [cited 2018 Maio 2]. Available from: http://www.unescap.org/sites/default/files/good-governance.pdf
http://www.unescap.org/sites/default/fil... , IMF¹⁵15 International Monetary Fund (IMF). Communiqué of the Interim Committee of the Board of Governors of the International Monetary Fund. Washington, D.C.: IMF; 1996. Available from: https://www.imf.org/external/np/sec/pr/1996/pr9649.htm
https://www.imf.org/external/np/sec/pr/1... , European Commission¹⁶16 Comissão Europeia. European Governance: a white paper. Brussels: Commission of the European Comunities; 2001 [cited 2018 Maio 2]. Available from: http://europa.eu/rapid/press-release_DOC-01-10_en.htm
http://europa.eu/rapid/press-release_DOC... and OECD¹⁷17 OCDE. Glossary of Statistical Terms. Paris: OECD; 2007. [cited 2018 Maio 2]. Available from: https://stats.oecd.org/glossary/download.asp
https://stats.oecd.org/glossary/download... . Having arisen focused on the developing countries, the concept of Good Governance and its structural principles were extended to the governance of developed countries where, in fact, they found the inspiration for the advocated good practices. This expansion of the concept’s application was particularly evident on the countries which suffered interventions by the international funding bodies, due to the 2008 crisis. It is also evidenced in the pursuit of the Sustainable Development Goals (SDG), highlighting the convergence of different countries in a common development ideal, although with a diverse achievement¹⁸18 Banco Mundial. World Development Report 2017: Governance and the Law. Washington, DC: World Bank; 2017..

Highlighting the World Bank’s doctrine regarding Good Governance, it is emphasized that it concerns two domains: a technical domain and a social domain. Within the technical level, the World Bank highlights the institutional capacity for the preparation and implementation of policies concern with the economic development and life quality. In the social level, it defends a plural society, in which the governance instances are open to the expectations and claims of civil society, accommodating them on the preparation of the pursuit measures. In the legal level, the technical concerns fall on values such as justice and freedom or, regarding the management of the institutions, on efficiency and effectiveness. The social concerns emphasize values such as the legitimacy, accountability (provision of accounts and liability), participation and transparency ¹⁹19 Williams, David e Young, Tom. Governance, the World Bank and Liberal Theory. Political Studies 1994; XLII:84-100..

Recently, the generalization of the concept’s use caused the appearance of proposals from other sectors, for example the civil society associations such as the British and Irish Ombudsman Association (Bioa)²⁰20 British and Irish Ombudsman Association (Bioa). Guide to principles of good governance. [Internet]. Carshalton: British and Irish Ombudsman Association [cited 2018 Maio 2]. Available from: http://www.ombudsmanassociation.org/docs/BIOAGovernanceGuideOct09.pdf
http://www.ombudsmanassociation.org/docs... , the Chartered Institute of Public Finance and Accountancy (CIPFA)²¹21 Commission for Good Governance in Public Services (CIPFA). The Good Governance Standard for Public Services. London: Commission for Good Governance in Public Services; 2004 [cited 2018 Maio 2]. Available from: https://www.jrf.org.uk/sites/default/files/jrf/migrated/files/1898531862.pdf
https://www.jrf.org.uk/sites/default/fil... ^,2222 International Public Sector Governance Framework (IFAC). Good Governance in the Public Sector - Consultation Draft for an International Framework. New York: International Public Sector Governance Framework; 2013 [cited 2018 Maio 2]. Available from: http://www.ifac.org/system/files/publications/files/Good-Governance-in-the-Public-Sector.pdf
http://www.ifac.org/system/files/publica... or the academics, such as Rhodes⁷7 Rhodes RAW. The New Governance: Governing Without Government. Polit Stud 1996; XLIV:652-667., Weiss²³23 Weiss TG. Governance, good governance and global governance: Conceptual and actual challenges. Third World Quarterly 2000; 21(5):795-814., de Hyden²⁴24 Hyden G, Court J. Governance and Development. World Governance Survey Discussion Paper. New York: United Nations University; 2002 [cited 2018 Maio 2] Available from: http://www.odi.org/sites/odi.org.uk/files/odi-assets/publications-opinion-files/4094.pdf
http://www.odi.org/sites/odi.org.uk/file... or de Smith²⁵25 Smith BC. Good Governance and Development. New York: Palgrave Macmillan; 2007., among others.

Within the scope of public health, the Good Governance concept is regarded as necessary and intellectually useful by the World Health Organization²⁶26 World Health Organization (WHO). Governance for health in the 21st century. Geneva: WHO; 2012 [cited 2018 Maio 2]. Available from: http://www.euro.who.int/__data/assets/pdf_file/0019/171334/RC62BD01Governance-for-Health-Web.pdf
http://www.euro.who.int/__data/assets/pd... , and its growing relevance in the sector is recognized by experts, such as Brand²⁷27 Brand H. Good governance for the public's health. Eur J Public Health 2007; 17(6):541.. It is deemed as an ideal to achieve through a continuous improvement process and is considered an ethical requirement and an instrument of change, which must continue to earn relevance on the health agenda.

Despite the existent relevant consensus on the operationalization methodology of the concept - which consists on the identification of principles that must guide the intervention of the State and remaining stakeholders, so that the governance quality is improved - the proposals are significantly different regarding the definition of the principles associated to Good Governance.

Considering the previously mentioned examples, it is possible to determine a total of 24 Good Governance principles, from which only five are present in almost all proposals. The five principles around which there is a broad consensus are: accountability; efficiency and effectiveness; transparency; participation of the stakeholders; and reinforcement of the rule of law.

This study adopted the Good Governance principles’ structure used by the United Nations¹⁴14 United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP). What is Good Governance? UNESCAP; 2009 [cited 2018 Maio 2]. Available from: http://www.unescap.org/sites/default/files/good-governance.pdf
http://www.unescap.org/sites/default/fil... , which includes the five principles previously mentioned and which have a broad consensus, plus the principles of: responsiveness; orientation towards consensus; and equity and inclusion.

We deem as useful to also add the principle of independency, which we extracted from the principles’ structure suggested by the British and Irish Ombudsman Association²⁰20 British and Irish Ombudsman Association (Bioa). Guide to principles of good governance. [Internet]. Carshalton: British and Irish Ombudsman Association [cited 2018 Maio 2]. Available from: http://www.ombudsmanassociation.org/docs/BIOAGovernanceGuideOct09.pdf
http://www.ombudsmanassociation.org/docs... .

In short, this research considered nine Good Governance principles, which definition - detailed in Chart 1, was adjusted to the context of the health area and to the current object of study.

Operationalization of the Good Governance principles

Each initiative was classified according to the proximity to each of the selected Good Governance principles, based in three criteria: nature of the initiative (relationship with each Area of Intervention); main objectives/purposes to achieve (specificity of the initiative); proximity to the Good Governance principles.

To each initiative were associated three Good Governance principles, according to the definition and operationalization model presented in Chart 1, allowing to prepare the terms of association presented in annex A and enabling the assessment of the level of incidence of each of the Good Governance principles. The association was carried out through an analysis of the extensive content to all characterization documents of each initiative which could be accessed.

To compensate for the asymmetry observed on the dimension and comprehensiveness of the initiatives, some of them were divided into sub-initiatives, thus aiming to improve their comparability. The accounting of the occurrence for each of the Good Governance principles was considered given this subdivision, assigning to each initiative a weight proportional to the number of sub-initiatives in which it is divided.

Selection and structuring of the sample

The actions by the Portuguese Government, in the health area and in the analyzed period, were grouped into nine areas, each type built to correspond to the (theoretical) key-characteristics associated to the previously mentioned three governance paradigms and to the measurement of the Good Governance practices.

Fifty initiatives carried out by the Ministry of Health on the analyzed period - which comprise a sample quite close to the universe - were selected, was we can see on Chart 2, and its selection considered representativity criteria of each of the nine intervention areas. The analyzed initiatives are distributed by the direct or indirect intervention areas of the Ministry of Health.

Collection of information on the selected initiatives

The process for the collection of information began with exploratory conservations with several entities of the Ministry of Health, aiming to identify the measures that were taken in the health sector, as well as the objective sources of information on the way they were structured and how the formulation and decision-making process was developed. This process began with the General-Secretariat of the Ministry of Health, in the person of the General-Secretary, Dr Sandra Cavaca, enabling the identification of the great concerns of the Minister of Health regarding the strengthening of the Good Governance practices in the entire Ministry and the recognition, on a global perspective, of the formulation and diffusion mechanisms used by the Ministry’s team regarding the emerging guidelines and policies (those already transposed to a legal diploma, published in the Official Gazette and implemented and also those who were under a formulation process). These first conversations also resulted in the scheduling of exploratory face-to-face interviews with the Ministerial Cabinet, ACSS - Central Administration of the Health System, SPMS - Shared Services of the Ministry of Health, IGAS - General Inspection of Activities in Health, DGS - General Directorate of Health, INFARMED - National Authority for Medicines and Health Products, among others. These interviews presented the ongoing research and the need for the project team to obtain information on the initiatives of those institutions that fit the principles of Good Governance presented. The research team had access to all relevant legislation, plans and activity reports, the interventions of the Ministerial team in different forums throughout the mandate, reports on the preparation of policies, expert opinions, reports on the practices adopted, minutes with the results of decision-making meetings involving multiple groups with participants from institutions of other ministries (Economy, Finance, among others) and other organizations (Trade Unions, Pharmaceutical Associations, Pharmaceutical Industry, Associations, etc...). Based on the collected information, 50 initiatives and sub-initiatives were selected and characterized - including aspects of the negotiation and decision-making process (a total of 86 types of actions implemented by the Ministry of Health in this period from 2011 to 2015 were worked on), and care was always taken to cross-check the information obtained, in order to ensure its reliability. Complementary interviews were also conducted with supra-ministerial bodies such as the Court of Auditors, in the person of the Counsellor Judge responsible for the health area, the Ombudsman, in the person of the Head of the Ombudsman’s Office and the Coordinator of the health area, and CReSAP - Commission for Recruitment and Selection for the Public Administration, an independent administrative entity responsible for recruiting and selecting candidates for senior management positions in the State Central Administration and assessing the adequacy of the profile of public managers, in the person of its President. From these conversations, in addition to the fundamental contribution to the understanding of the context and initiatives, it was also possible to obtain information on the perception that these stakeholders had of the Government’s action in the health area - which, in general, was that there was a great openness to dialogue and cooperation by the ministerial team - but as the focus of this study was not the stakeholders’ perceptions of the government’s action, we chose not to consider the information collected, which essentially focuses on the assessment that these stakeholders made of the participation/cooperation of their institution with the ministerial team.

Analysis and discussion of the outcomes

The construction of the association matrix - using the methodology described - between the 50 initiatives analyzed and the nine principles of Good Governance (Chart 3), allowed - without taking into account the segmentation by areas of intervention - to obtain the overall relative weight of each of the principles of Good Governance. The analysis of these relative weights revealed a predominance of the principles of “effectiveness/efficiency” and “transparency”, with a combined relative weight of 44%, indicating a clear concern of the Ministry of Health to promote the satisfaction of users’ needs with a rational use of resources and to promote the confidence of the various stakeholders in the decision-making processes.

If in the case of the concern with “efficiency/effectiveness” it seems legitimate to us to assume that it results largely from an imposition of the MoU, the concern with transparency already, in our opinion and that of the majority of the interviewees in the exploratory talks, should be attributed to a reflection of the way the ministerial team acts.

The improvement of the “responsiveness” of the health system - meeting the needs of users - the “accountability” for the decisions taken and the contribution to the “strengthening of the rule of law” - creating conditions for a fair and effectively and impartially applied legal system in the health area - were also visible concerns in the Ministry of Health’s actions, assuming a joint relative weight of 35%.

Concerns about “stakeholder participation” in decision-making processes, “equity” in access to health care, the “guarantee of independence” of managers and the creation of “consensus” around the main objectives to be defined and how to achieve them are also present in the work of the ministerial team and have a joint relative weight of 21%.

Analysis per area of intervention

When the data from the association matrix (Chart 3) are analyzed, taking into account the aggregation of initiatives in areas of intervention, it becomes possible to segment the analysis of the relative weight of each of the principles of Good Governance. The analysis of the degree of incidence of the principles in the different areas of intervention shows a significant difference between areas.

The significant number of areas of intervention and principles generates a high number of relative weights, which become complicated to analyze. Chart 4 seeks to facilitate this task by showing the differences in the incidence of Good Governance principles in the various areas of intervention, identifying for each principle the areas of intervention with maximum incidence. Each initiative is associated with 3 principles of Good Governance, which implies that the incidence of each principle is a maximum of 33%.

At a first level, we have the principle of “effectiveness/efficiency” which is present with maximum incidence in 4 of the 9 areas of intervention, followed by the principles of “transparency” and “strengthening of the rule of law”, present with maximum incidence in 3 areas. This evidence reinforces the conclusions indicated in the previous point and indicates that these principles are being applied across the board. At a second level are the principles of “responsiveness”, with maximum incidence in 2 areas of intervention and the principles of “stakeholder participation”, “consensus orientation” and “independence”, which have maximum incidence in only one area.

Analysis per Good Governance principle

In order to better understand how the principles of Good Governance were applied in each of the areas of intervention, the table of association presented in Chart 3 was read in reverse, calculating the relative weight of each area of intervention in the incidence of each of the principles of Good Governance.

When analyzing the data from the perspective of the principles of Good Governance, it can be seen that the weight of the intervention areas in each principle varies significantly, and it is possible to identify two distinct behaviors: 1) principles with a more transversal incidence (maximum dispersion) and which are present, albeit with variable weights, in several intervention areas; 2) principles whose incidence is mainly concentrated in one intervention area (maximum concentration), which reaches a relative weight above 50%. In order to facilitate the analysis of these two behaviors, we constructed Graph 1, in which each principle of Good Governance is represented according to the number of intervention flights to which it is associated.

It should be noted that, at this point, it is not a question of analyzing the degree of overall incidence of Good Governance principles, but of assessing their level of dispersion (transversality) across the different areas of intervention (in Graph 1, for example, the principle of transparency is associated with eight of the nine areas analyzed, regardless of their degree of incidence in each area).

In Graph 1 it is possible to identify three behavior profiles: 1) The principles that demonstrate a more transversal application by the Ministry of Health are clearly those of “transparency” and “effectiveness/efficiency”, present in eight of the nine intervention areas, although their degree of incidence in each of the areas does not exceed 29% in the case of “transparency” and 30% in the case of “effectiveness/efficiency”; 2) the principles of “stakeholder participation”, “responsiveness” and “accountability”, with a lesser degree of transversality, but still without an intervention area with a relative weight of more than 50%; 3) the principles of “orientation towards consensus”, “independence”, “equity and inclusion” and “strengthening of the rule of law”, with a clear predominance of one of the intervention areas, which presents a relative weight clearly above 50%.

Graph 2 shows the principles of Good Governance that fit into the third profile identified in Graph 1, with an indication of the predominant area of intervention and the respective relative weight.

These results come as expected. In fact, the process of aggregating initiatives by area of intervention (e.g. initiatives in the area of agreements) associates, in some cases, more immediately (as is the case of the four areas indicated in graph 2) a given area with a given principle of Good Governance (e.g. the area of agreements is more naturally associated with the principle of “consensus orientation”, which explains its great concentration when we specifically analyze this principle).

Conclusions

With regard to the analysis of the quality of governance of the health sector in the period under review, and using the application of the principles of Good Governance as a criterion, it can be concluded, in global terms, that there was a clear predominance of the principles of “transparency” and “effectiveness/efficiency”. The public action of the Ministry of Health shows a clear concern with the promotion of the satisfaction of users’ needs with a rational use of resources and with the adoption of measures that stimulate the confidence of the various stakeholders in decision-making processes. If in the first case it seems legitimate to us to assume that it results, to a large extent, from an imposition of Troika, very present in the measures provided for in the MoU, the concern with “transparency” should already, in our opinion, be attributed to an option for action by the ministerial team. The concern with improving the “responsiveness” of the health system, meeting the needs of users, with “accountability” for the decisions taken and with contributing to the “strengthening of the rule of law” - creating conditions for a fair and effectively and impartially applied legal system in the health area - are also visible, at a second level, in the work of the Ministry of Health. With less focus, although present, there are concerns about the “participation of stakeholders” in decision-making processes, with “equity” in access to health care, with the guarantee of the “independence” of managers and with the creation of “consensus” around the main objectives to be defined and the way to achieve them.

Analyzing the framework of association between the 50 measures considered and the 9 principles of Good Governance, segmenting by the 9 areas of intervention defined, it is possible to understand that the incidence of the principles is not identical in all areas, which indicates differentiated concerns on the part of the ministerial team. The principles of “transparency” and “effectiveness/efficiency” are present in eight of the nine areas of intervention, proving to be a more transversal concern. At the other extreme are the principles that are essentially associated with a single area of intervention, such as: “orientation” towards consensus”, with an incidence of 88% in the Agreements area; “independence”, with an incidence of 57% in the Ethics area; “strengthening the rule of law”, with an incidence of 56% in Control; and “equity/inclusion”, with an incidence of 53% in the NHS Centre for Citizens.

Acknowledgements

The authors wish to thank for all the support provided by the contacted entities. Without them, it would have not been possible to access all documentation that supports this study.

References

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History