Mitigating regional health inequities through community care: a multi-criteria analysis in Portugal

Background

European health systems are challenged by demographic aging and regional inequalities. In Portugal, the sustainability of the National Health Service is predominantly evaluated through hospital-centric metrics focused on short-term expenditure, systematically undervaluing community-based care. This study proposes a paradigm shift from viewing primary care as a cost to recognizing it as a structural place-based investment.

Methods

A theoretical-conceptual study was conducted, supported by a structured narrative review and documentary analysis of the Portuguese health system. Combining Value-Based Health Care principles with regional development theories, we developed a Multi-Criteria Decision Analysis (MCDA) conceptual model. The framework aggregates indicators across four dimensions: direct economic value, health value, social value, and territorial value.

Results

The evidence demonstrates that proximity models proactively address social determinants of health. Community interventions prevent acute decompensations, reducing chronic emergency department visits and mitigating avoidable hospitalizations. The MCDA model reveals that these teams generate measurable value by transforming traditional care expenditure into effective economic and social returns, thus actively reducing inter-regional disparities.

Conclusions

Evaluating community care exclusively through traditional cost-effectiveness metrics systematically underestimates its systemic impact. The proposed multi-criteria model provides policymakers with a robust tool to quantify the indirect costs avoided and the social cohesion generated, proving that investing in community-based primary care is essential for long-term health system sustainability.

Key messages

• Community care is a structural place-based investment that reduces avoidable hospitalizations and regional health inequities.

• A multi-criteria evaluation model renders the economic, clinical, and social value generated by community teams visible to policymakers.