An exploratory analysis of the

public oral health policy for children in Portugal

Aida Isabel Tavares1
CEISUC, University of Coimbra, Portugal
ai.tavares@fe.uc.pt

Abstract
Purpose: The dental care program for children in Portugal is run under a public-private
partnership based on a voucher scheme. Some major changes to the scheme were introduced
in 2009. This work seeks to understand if the increased number of children receiving medical
attention is motivated not only by the increase in the relative number of dentists and
hygienists but also by the change in the organization and implementation of the program by
regional health authorities (RHA).
Design/methodology/approach: An empirical analysis is carried out for the period 2007-10,
employing two linear panel data regressions for the coverage and usage of dental care under
the national dental care program.
Findings: The main results show that both the coverage and the usage of dental vouchers and
dental care under this program depends on the relative number of dentists, on the relative
number of hygienists and on the efficiency of the RHA in organizing and implementing the
program.
Originality/value: This work contributes to the discussion and understanding of the factors
explaining the potential success of the National Program for Dental Health Care.

Key words: public dental policy, dental voucher, linear regression

JEL classification: I18, C23, C67

The author is grateful to Joana Pinho for assisting with the DEA analysis and to Julian Tice for revising
the manuscript.

1. Introduction
Oral dental care is not included in the Portuguese National Health System (NHS). For
this reason an extremely high percentage of children have no access to oral health
care, with subsequent implications for their oral health. The quality of oral health is
considered to be moderate to low. According to the Ministry of Health2, the average
number of lost and damaged teeth per child of twelve years old is 2.951 and the
percentage of children free of caries at age six is 33%. Moreover, oral health varies
greatly according to the socio-economic status of the family (Melo, 2001). No
systematic surveys have been conducted in Portugal to monitor the health status of
Portuguese children since 1997 (Almeida, 1997). Although in 1999 a questionnaire was
given to nearly 1600 children showing that the prevalence of dental caries stood at
46.9% for six-year-olds and 52.9% for twelve-year-olds, and also the DMFT index3 was
estimated at 2.1 and 1.5, respectively (Almeida et al, 2003). The goal of European
strategy for oral health is that by 2020 80% of children aged six should be free of caries
and, by twelve years old, the DMFT index level should be less than 1.53 (AFSPS, 2002).
Oral health care in Portugal is privately offered or it may be (partially) covered by
public health subsystems4, under private-public partnership agreements, or by private
health insurance. This definitively does not cover the whole population while also
requiring high co-payments. At present, most of the population has no plan for access
to medical dental care5. In order to help fill this void in the NHS, a National Program for
Dental Health Care (NPDHC) was launched in 2005 to guarantee dental care to some
socially disadvantaged groups, including children, the elderly, pregnant women and
HIV patients.
This program is based on private-public partnerships under which private dentists are
paid an incentive to provide dental care, and beneficiaries are given a voucher to
2

This statistical information is provided by Diegues (2003) who wrote the guidelines for the presence of
fluorine in water for the Ministry of Health.
3
The DMFT index represents the number of decayed, missing and filled teeth.
4
A public health subsystem refers to a public health insurance scheme aimed at particular groups of
professionals such as public sector employees, the military and other members of the security forces
and also court and judicial employees (Barros and Simoes, 2011).
5
Medical dental care refers to the care of oral health as provided by dentists and hygienists. Here
medical dental care mainly relates to basic care aimed at the treatment of caries.

spend on oral health care provided by dentists. In 2009, some changes took place in
the implementation of the NPDHC in order to make it simpler and promote coverage
and usage of the provided dental care.
This work provides an exploratory analysis of the impact of this change on the
coverage and the usage of dental services provided under the NPDHC by children in
school for the period 2007-10.To achieve this aim, two linear regressions are estimated
to explain the level of coverage and usage of dental care provided under the NPDHC.
The main results show that both the relative number of dentists registered in the
NPDHC and the relative number of hygienists contribute positively to the coverage and
usage of the dental care provided under the program. Moreover, evidence shows that
the efficiency of the Regional Health Authorities (RHA) in implementing the NPDHC
plays some role in determining the coverage and usage of the dental vouchers.
This work is organized as follows. In Section 2 a description of the Portuguese National
Program for Dental Health Care is given. Section 3 describes the data and the
econometric method used. The results are discussed in Section 4. Finally, the
conclusion is given in Section 5.
2. The National Program for Dental Health Care in Portugal
Basic health care, such as dental care, particularly at young ages, may be seen as a
merit good which calls for some public intervention (Gupta, 2010). The National
Program for Dental Health Care (NPDHC), which, as far as we are aware, is unique of its
kind in Europe (Anderson et al, 1998; Holst et al 2001; Birch and Anderson, 2005;
Widstrom and Eaton, 2004), was launched in 2005. Its main aims are to reduce the
incidence of caries, increase knowledge of oral health, and promote equity of access to
dental care. This health program is aimed at different target groups: children, the
elderly, pregnant women and HIV patients. In this study, the focus is on children under
16 years old and in school.
The NPDHC is a public-private partnership where private dentists are paid an incentive
by the National Public Health System to provide health care to children, and children
3

are given a voucher (Bredford and Shaviro, 1999) to pay for the dental care. The
program is fully financed by a public budget of the Ministry of Health. The
responsibility for the implementation of the program lies with the RHAs who
coordinate the different providers: dentists, hygienists and primary health care
centers.
Some guidelines to assist in the correct application of a voucher system are listed in
Bailey (2004). The initial implementation of the NPDHC failed to meet some of those
guidelines for a proper voucher program, with these failings being rectified in the 2009
revision.
Up to 2009 the NPDHC was aimed at children aged 7, 10 and 13 years old, who were
given a voucher, by a hygienist in school or in a primary health care center, for
treatment with a predetermined dentist, precluding competition among providers
(Burwick and Kirby, 2007). Dentists were paid an incentive of 75 per child treated, no
matter the number of consultations or number of treated teeth. No co-payment was
required by children/parents. Children (and their parents) were not free to choose the
dentist they would go to for treatment using the voucher. Dentists gained entry to the
program by public competition. The number of children in receipt of treatment
reflected the number of vouchers used.
After the changes implemented in 2009, children aged 7, 10 or 13 years old may
receive up to three vouchers6 to get treatment at the dentist of their choice, as long as
they are registered in the program. Dentist are now paid 40 for each voucher7,
entitling the child to one consultation and at least one treated tooth. Parents and
children are free to choose the dentist from the list of doctors enrolled in the program.
Moreover, the introduction of an information system (called SISO) simplified the
contractual relationship with private dentists and also permits the implementation of
the policy to be monitored. The number of children that receive treatment coincides
with the registered number of first-use vouchers or consultations and the number of
consultations per child is limited, as defined by the program.
6

Two vouchers may be given to children aged 7 and 10 and three vouchers for children aged 13.
No co-payment is required from children/parents.

A summary comparing the basic features of the NPDHC before and after 2009 is
presented in Table 1.
Table 1 Comparison of NPDHC features
dentist payment
Before 2009
After 2009

fixed:
75 per child
per service:
40 per consultation

dentist
participation
mechanism

monitoring
mechanism

freedom to
choose dentist
by patient

competition

no

no

registration

yes

yes

One of the major changes was the payment mechanism to dentists, which provides the
incentive to enroll and treat children. The literature on incentives (Baker, 1992;
Gibbons, 1987; Lazear, 1986) basically shows that a fixed payment does not provide
incentives to illicit effort by the contracted agent (dentist); while an incentive based on
piece-rate or on performance motivates the agent to exert effort to execute a task.
The changes that occurred in the NPDHC in 2009 clearly reflect the difference between
a fixed payment offered initially to dentists and a piece-rate incentive offered
afterwards. This change motivates more dentists to register in the program and to
treat children.
Hygienists are paid a fixed salary and are contracted by each RHA to be employed in a
particular primary health care center. Their main role in the NPDHC is to provide
educational presentations to children in schools and to refer children with unhealthy
teeth to dentists.
This work focuses on the period 2007-10 not only because of data availability but also
because in 2007 the Ministry of Health approved the form and terms for contracting
dentists and the NPDHC financial budget.
3. Data and Method
3.1. Descriptive analysis

Statistical information relating to the public policy for Portuguese oral health is scarce.
Some numbers are published in the annual reports of the five regional authorities
(RHA: North, Centre, Lisbon and Tagus Valley, Alentejo and Algarve) and also in the
Auditing Report for the NPDHC (Tribunal de Contas, 2009). Some data was provided
only on request but most of the data is not publicly disclosed.
Since the implementation of the NPDHC is the responsibility of the regional health
authorities (RHA), a description of each region helps to highlight the differences. Table
2 shows the three main geographic features: area in square kilometers, number of
cities and inhabits per square kilometer.
Table 2: Main geographic features of the regions
km2

nr cities

inhab/km2

North

21285.9

49

175.16

Centre

28199.4

36

84.34

Lisbon and Tagus Valley

3001.9

16

963.73

Alentejo

31604.9

18

24.38

Algarve

4996.8

11

82.46

Source: INE, 2004

One of the most relevant economic indicators of these regions is the annual gross
family income per capita in Euros, as presented in Table 3.It can be observed that over
the period 2007-10, there has not been a significant change in this indicator.
Table 3: Annual gross family income per capita, in Euros

North

2007
9260

2008
9626

2009
9633

2010
9931

0.04

0.00

0.03

Centre

9721

10093

10151

10396

0.04

0.01

0.02

13973

14539

14210

14772

0.04

-0.02

0.04

Alentejo

10091

10515

10821

11046

0.04

0.03

0.02

Algarve

11852

12088

12222

12243

0.02

0.01

0.00

Lisbon and Tagus Valley

Source: INE

The evolution of registered dentists and consultations show the main effects of the
program. From Table 4, it can be observed that after the change in the policy, in 2009,
there is a significant increase in the relative number of dentists registered.
Table 4: Registered number of dentists per 1000 children in school
North
Centre
Lisbon Tagus Valley
Alentejo
Algarve
Portugal (total)

2007
1.12
1.59
0.66
0.76
1.66
1.10

2008
1.59
1.59
0.80
1.06
2.02
1.36

2009
3.42
2.42
1.90
1.35
1.16
2.55

2010
3.78
2.85
2.22
1.55
1.46
2.89

Moreover, looking at Table 5, the number of consultations shows a significant increase

in 2009. However, the number of consultations per dentist decreases (except in 2010).
This may reflect the fact that the increase in the number of dentists is larger than the
increase in the number of consultations.
Table 5: Number and variation of consultations
2007
Total first consultations
%
Total first consultations per dentist
%
Total consultations
%
Total consultations per dentist
%
Note: % is the percentage increase.

54211

2008

64048
18.1
45.5
42.2
-7.3
115827 135910
17.3
97.3
89.5
-8.0

2009

2010

116040
81.2
37.5
-11.1
244486
79.9
78.9
-11.8

140847
21.4
40.9
9.1
299324
22.4
86.9
10.1

It is worth to notice that the increase in the number of dentists registered in NPDHC is
much larger than the increase in the number of dentists certified to practice dental
medicine as shown in Table 6. The certification of dentists, who want to practice dental
care, is compulsory and it is given by the dentists professional organization called
Ordem dos Mdicos Dentistas (OMD).

Table 6: Number of dentists

Nr certified
dentists

%
Nr dentists in
NPDHC

5434

5903

6421

6905

8.6

8.8

7.5

1191

1519

3098

3443

27.5

103.9

11.1

Table 7 gives the correlation between the total number of consultations (and the
number of first time consultations) and the number of dentists in the program (under a
population averaged model). Here a clear positive correlation can be seen, as
anticipated. This fact may help in understanding the role that incentives play in
attracting dentists to the program, who in turn are available to offer more
consultations and to treat more children.
Table 7: Linear Correlations
Number of
Number of
Significance
Significance
total
coefficient
first time
coefficient
P>z
P>z
consultations
consultations
Number of
Number of
dentists in
80.028
0.000
dentists in
35.494
0.000
program
program
Constant
2760.514
0.190
Constant
2339.451
0.019
Wald chi2
639.5
0.000
Wald chi2
521.57
0.000
Note: GEE population-averaged model (nr obs=20; nr groups=5; obs per group=4)

The NPDHC is also based on the work of hygienists. In Table 8 the number of hygienists
per 1000 children is presented for each different RHA. It can be seen that this number
remains largely unaltered over time for each RHA, while at the same time varying
substantially across RHAs.

Table 8: Number of hygienists per 1000 children

2007

2008

2009

2010

North

0.0092

0.0114

0.0103

0.0107

Centre

0.0829

0.0817

0.0752

0.0772

Lisbon and Tagus Valey

0.2034

0.2036

0.1922

0.1895

Alentejo

0.1649

0.1528

0.1653

0.1696

Algarve

0.1294

0.2241

0.2093

0.2064

Portugal

0.0939

0.0990

0.0930

0.0941

The ratio of hygienists to dentists may be of more relevance. In most cases this ratio
decreases over time because while the program saw increasing number of dentists the
number of hygienists remained relatively stable. In Table 9, the relative number of
hygienists to dentists in the program and the absolute number of hygienists is
presented.

Table 9: Ratio of hygienists to dentists (number of hygienists in brackets)

2007
2008
2009
2010
North
0.008 (4)
0.007 (5)
0.003 (5)
0.003 (5)
Centre
0.052 (20) 0.051 (20) 0.031 (20) 0.027 (20)
Lisbon and Tagus Valley
0.309 (60) 0.253 (63) 0.101 (63) 0.085 (62)
Alentejo
0.218 (12) 0.145 (12) 0.123 (14) 0.109 (14)
Algarve
0.078 (6) 0.111 (11) 0.180 (11) 0.141 (11)
Portugal
0.086
0.073
0.036
0.033

Finally, in Table 10, the percentage of children covered by the NPDHC is shown. It can
be seen that the number of children receiving dental care in Portugal has significantly
increased from 2009 on.
Table 10: Percentage (%) of children in school covered by NPDHC
North
Centre
Lisbon and Tagus Valley
Alentejo
Algarve
Portugal (total)

2007
3.80
6.36
3.72
7.39
13.22
4.99

2008
4.14
6.50
4.13
8.42
21.50
5.71

2009
13.55
9.93
4.36
5.35
9.87
9.55

2010
14.78
12.64
7.92
6.75
13.97
11.83

3.2. Method
To be able to analyze the impact of the changes in the NPDHC on the dental care
coverage and usage, two linear regressions are estimated using panel data from five
RHAs over four years (2007-10). Estimation of the panel data is carried out considering
fixed effects (FE), because, as described above, each region has particular
characteristics that influence the demand for dental health care, which are also
9

invariant over time. Regression estimation was also carried out for the average of the
RHAs, as a population averaged (PA) model, and for random effects (RE), as a
comparison estimation. Estimations were provided using STATA v10.0. The first linear
regression estimates the determinants of the coverage provided by the dental care
program:
coverage = c1 + a1 relnrdent + a2 effscores + a3 t + a4 hygdent + e1.
(+)
(+)
(+) (+)
The second linear regression looks at the usage of dental care:
usage = c2 + b1 relnrdent + b2 effscores + b3 t + + b4 hygdent + e2.
(+)
(+)
(+)
(+)
The expected signs for the estimated coefficients are presented in parentheses. All
signs are expected to be positive indicating a positive relationship between the
independent and dependent variables.
The dependent variable coverage is given by the number children who receive
treatment per 1000 children in school. The other dependent variable is usage which is
given by the number of total consultations per 1000 children.
The explanatory variables are the following:
i) relnrdent the relative number of dentists.
This variable may be measured in two different ways. Firstly, the relative number of
dentists is given by the ratio of the number of dentists registered in the NPDHC to the
total number of dentists registered in the professional organization of dentists
(relnrdent1). This definition provides a control for the increasing number of dentists in
the market willing to offer consultations. Secondly, this variable may be measured by
using the ratio of the number of dentists registered in the NPDHC to 1000 children in
school (relnrdent2). In this way not only the importance of the number of dentists is
captured but also the coverage of each dentist.
ii) effic the efficiency scores obtained by DEA estimate for each RHA.
These efficiency scores measure the ability of each RHA to implement efficiently the
dental care program. The explanation of these scores is provided next section.

10

iii) t a dummy variable which takes a value of 0 for 2007-08 and a value of 1for 200910. This variable checks if there is any difference between the two periods under
study.
iv) hygdent the ratio of the number of hygienists to number of dentists registered in
NPDHC.
The demand for dental health care is determined by several factors, such as prices,
income, education, availability, accessibility and other individual characteristics (HolmPederson et al, 2009; Pinilla and Gonzalez, 2001). However, it can be argued that at an
aggregate level some of these features may not be captured in statistical data or they
may be constant over time, such as income and market prices. Data for market prices
are not available, but taking the ADSE public health (insurance) subsystem as a
reference shows that co-payment prices have remained constant since 20048. ADSE is
the health insurance subsystem for public sector workers and also the biggest health
insurance program in Portugal. Other characteristics such as income and education are
unchanged over the period. Therefore, on an aggregated basis we are able to capture
availability, accessibility and also the efficiency of implementing the policy, using the
explanatory variables just described.
3.3. Efficiency scores
The implementation of the NPDHC is the responsibility of the RHA. In order to measure
their ability to use their structure and organization to implement the NPDHC, that is, to
transform the measurable inputs of the program (the number of dentists in the
program and the number of contracted hygienists) into outputs (the number of
children receiving treatment and the total number of consultations), an efficiency
analysis is performed (Farrell, 1957).

Available from http://www.adse.pt/.

11

Data envelopment analysis (DEA)9 measures technical efficiency of organizations with

an unknown production function. This is the case of the RHA when implementing the
NPDHC. DEA analysis is widely used to measure efficiency in the health sector (Tieman
and Schreyogg, 2012; Holingsworth, 1999, 2003, 2008) in an analogous manner to that
used here.
This method allows the estimation of efficiency scores for the RHAs and it assumes the
following:
- constant returns to scale10,
- a convex production possibility set,
- two inputs: here the number of dentists in the program and the number of
contracted hygienists,
- two outputs: here the number of children receiving treatment and the total number
of consultations,
- an input-oriented approach11,
- the most efficient unit (RHA) is used as a benchmark for measuring the efficiency of
the other units (RHAs).
After applying DEA the efficiency scores are estimated, as presented in Table 11. If the
efficiency score is less than 100 then that RHA is inefficient relative to those that have
a score of 100. The efficiency scores are then used as a control variable for the
econometric estimation explained above.
Table 11: Efficiency scores
North
Centre
Lisbon and Tagus Valley
Alentejo
Algarve

2007
100.00
66.43
55.08
100.00
95.72

2008
89.30
68.59
48.34
87.27
100.00

2009
100.00
72.97
28.98
45.12
89.14

2010
100.00
86.28
53.65
52.69
100.00

DEA analysis or Data Envelopment Analysis is a non-parametric method used to measure efficiency.
This method was developed by Charnes, Cooper, and Rhodes (1978). It uses inputs and outputs to
deduce a frontier of production possibilities, without employing an explicit production function.
10
It is assumed the decision making units are performing at an optimal scale.
11
Under constant returns to scale, the input and output approaches yield identical results. The inputoriented approach minimizes the inputs for a given amount of output while the output-oriented
approach maximizes the output for a given amount of input.

12

4. Results and discussion

4.1. Results
The results estimates are presented in the tables in this section. Firstly the results
explaining coverage are presented, followed by those for usage of dental care under
the NPDHC.
The econometric method used to estimate the regression for NPDHC coverage uses
fixed effects (FE), as previously stated, due to the individual characteristics of the
regions where the RHAs implement dental care policy. The Hausman test also confirms
that fixed effects represents a correct specification for the estimation because no
systematic difference was found between the estimated coefficients under fixed
effects and random effects.
The results for the coverage equation under fixed effects (FE) are in Table 12. Results
show that the number of dentists per 1000 children and the ratio of hygienists to
dentists have a positive effect on the program coverage. The dummy time variable
indicates that the changes in the NPDHC had no positive impact on the coverage.
Finally, the efficiency of the RHA has a positive and significant effect on the number of
children using a voucher to receive dental care.
In order to capture an average behavior of all HRA, an average population estimation,
identical model was estimated with Generalized Estimation Equation (GEE) and the
results are presented in model 5 of Table 13. In average all the previous results are
confirmed. Finally, in Table 12, model 6, presents the estimation for random effects
(RE).

13

Table 12: Coverage Equation, FE

Model 1
coef

Model 2
P>t

coef

Model 3
P>t

relnrden1

Model 4

coef

P>t

763.5071

0.0020

coef

P>t

58.516

0.0000

relnrden2

58.341

0.000

53.3030

0.0000

effic

0.716

0.002

0.7750

0.0230

0.7300

0.1580

-30.731

0.000

-23.2010

0.0390

-12.6543

0.4350

-34.384

0.0070

hygdent

564.578

0.001

const

-125.071

0.000

-52.0640

0.0490

-16.3271

0.6730

4.0590

0.7360

F test

68.54

0.000

30.37

0.000

9.72

0.002

29.27

0.000

F test e=0

7.91

0.003

18.89

0.000

7015

0.004

19.81

0.000

Table 13: Coverage Equation

Model 5, PA
coef
P>z
relnrden2
57.495
0.000
effic
0.848
0.000
t
-28.606
0.000
hygdent
504.261
0.000
const
-127.111
0.000
Wald chi
366.18
0.000

Model 6, RE
coef
P>z
57.399
0.000
0.864
0.000
-28375
0.000
501.331 0.000
-127.903 0.000
266.62
0.000

The results for the equation explaining usage are presented in Tables 14 and 15.
As expected, observing the results of Table 14 shows identical results to those
obtained for coverage regressions. In bold are the statistical significant coefficients.

Table 14: Usage equation, FE

Model 1
coef
P>|t|

Model 2
coef
P>|t|

relnrden1

Model 3
coef
P>|t|
1326.698

0.002
102.153

0.000

0.985

-42.973

0.101

-64.698

0.331

22.458

0.410

0.000

13.91

0.000

20.23

0.000

0.001

5.89

0.007

9.67

0.000

relnrden2

99.326

0.000

88.410

0.000

effic

1.914

0.000

2.042

0.005

1.914

0.038

-29.804

0.009

-13.487

0.509

0.513

hygdent

12230292

0.000

const

-283.696

0.000

-125.512

0.020

112.04

0.000

28.87

6.37

0.007

90.13

F value
F test e=0

Model 4
coef
P>|t|

14

Table 15: Usage equation

Model 5, PA

Model 6, RE

coef

P>z

coef

P>z

relnrden2

95.688

0.000

97.303

0.000

effic

2.350

0.000

2.156

0.000

-21.053

0.038

-24.529

0.020

hygdent

791.911

0.080

886.040

0.000

const

-259.800

0.000

-258.010

0.000

424.08

0.000

364.62

0.000

Wald chi2

4.2. Discussion
The literature amply covers the most common factors determining the demand for
dental care. As listed before, these include price, income, education, accessibility and
availability (Holm-Pederson et al, 2009; Pinillan and Gonzalez, 2009).
The aim of this work is to determine the main factors influencing the coverage and the
usage of dental care under the NPDHC. The sample used for the econometric analysis
is small, which does not allow many control variables to be included. However, in this
case some control variables are not needed.
Prices for dental care do not change significantly when taking the ADSE co-payments
as a benchmark. Since 2004 the ADSE co-payments have held constant.
No significant change in income has been seen between 2007-10. Moreover, it is highly
unlikely that the level of education has changed significantly during this period.
Accessibility is controlled by the NPDHC program with a voucher being issued to all
children referred by a hygienist. This follows either from a school or a primary health
care center visit. The ratio of hygienist to dentists, as given above for the period, helps
better understand the importance of hygienists. Results from this study show that this
ratio is relevant: the number of hygienists, with their role in providing vouchers to
children, contributes greatly to the efficacy of the NPDHC. Hygienists not only provide

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education on oral health but also and, most importantly, they are responsible for
referring children to dentists. Hygienists work in this way as gatekeepers.
Availability is most basically expressed by the number of dentists. This indicator is
captured in two different ways in the estimated models. The increase in the number of
certified dentists can be controlled for by comparing the relative number of dentists to
the total number of dentists in the market. However, this indicator seems not to be an
appropriate control variable since when included in the coverage and usage equations,
model 3, the other independent variables lose statistical significance or lose
explanatory power. This may be due to the model being wrongly specified or even
endogeneity.
The most appropriate variable capturing availability seems to be the number of
dentists per 1000 children. This control variable makes more sense when one thinks
that the more dentists there are in the program, the larger the choice given to children
and the larger the potential for children to participate in the program. As the results
confirm, the larger the relative number of dentists, the larger the coverage and the
usage of dental care under the NPDHC. Additionally, as confirmed before, the positive
correlation between the number of dentists enrolled in the NPDHC and the number of
consultations provides some evidence that the incentives paid to dentists may play
some role in the results of the program. In this way availability may be linked to the
incentives paid to dentists, who in turn are the most relevant feature of availability.
In addition to the most usual factors determining the demand for dental care, we have
included an explanatory variable that captures the ability of each RHA to efficiently
implement the dental care program. This variable is tested in some of the models
estimated. It can be recalled that the inputs and outputs of DEA analysis are absolute
numbers which are tested for each RHA. Thus, correlation with the other control
variables in the econometric analysis is unlikely. As expected, efficiency of the RHA has
a positive and significant impact on the coverage and usage of dental care within the
NPDHC.

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Finally, the t-time dummy variable was included to capture any structural break in the
observations during the period 2007-10. However, the time series in this panel data is
very short and results may not truly reflect reality. Nevertheless, results indicate that
the 2009 break negatively impacts the coverage and usage of provided dental care.
This means that holding all the other control variables constant, the effect of the policy
change on the coverage and usage was negative. This result is awkward since one
would expect that the gains obtained from learning and experience, as well as the
gains from the more advanced information system would contribute to a higher
coverage and usage of the dental vouchers of the program. However, it may be these
non-observable variables are captured in the efficiency of the RHA. These results for
the t-time variable may call for further research.
The limitations of this work are rooted in the small sample size and small number of
observed variables. This fact prevents a more thorough comparison of the policy
before and after 2009 and the consideration of other possible explanatory variables
such as fluoridated water, lifestyles, cultural and social peer effects, private health
insurance and dentist competition. Moreover, the available data does not allow an
analysis of the competition for dental care provided by the NPDHC and by other health
insurance schemes. It is also not possible to directly test the effect of the change in the
incentives offered to dentists and in the number of consultations provided under the
NPDHC.
Despite these limitations, this work has contributed to an analysis of the effect of the
change of the NPDHC policy and to understanding the main factors that explain the
potential success of the NPDHC, meaning the coverage and usage of dental vouchers
by children who usually have no access or have a restricted demand for dental care.

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5. Conclusion
The dental care program for children implemented in Portugal is a public-private
partnership based on a voucher scheme. The NPDHC was launched in 2005 and under
went some significant changes in 2009, leading to an increase in the number of
children treated. These changes affected the incentives offered to dentists, the
registration mechanism of dentists in the program, the monitoring system and the
freedom of children/parents to choose a dentist. Given this scenario, the main goal of
this work has been to find evidence identifying the main factors determining the
coverage and usage of dental vouchers provided under the NPDHC and the effects of
the change of the policy in 2009. To achieve this aim, two linear equations were
estimated for panel data over the 2007-10 period, divided over five RHAs in order to
explain coverage and usage of the NPDHC.
The results show that both the relative number of dentists registered in NPDHC and
the relative number of hygienists contribute positively to the coverage and usage of
the dental care offered by the dental vouchers. Moreover, acknowledging the
importance of incentives attracting dentists to the program, paying dentists per service
may help explain their positive contribution to the coverage and usage of dental
vouchers. Results also show that the efficiency of the RHA implementing the NPDHC
plays some role in determining the coverage and usage of dental care under the
program. Finally, it was found that there was a negative impact from the change in the
dental policy, as revealed by a time dummy variable.
The results described here are important for policy makers, and of particular relevance
to the case of Portugal. The success the NPDHC, measured by the coverage and usage
of dental vouchers, depends on the expected factors such as the number of
professionals but also on other not so obvious factors such as the efficiency of the
RHA. Moreover, there is evidence that some factors exist that reduce the success of
the NPDHC which may warrant further research.

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