Logistical Challenges in Home Health Care: A Comparative Analysis Between Portugal and Brazil

Abstract

Background: This study aims to compare the logistical challenges of Home Health Care (HHC) services in Portugal and Brazil, highlighting the structural and operational differences between both systems. Methods: Guided by an abductive research approach, data were collected using a semi-structured survey with open-ended questions, applied to 13 HHC teams in Portugal and 18 in Brazil, selected based on national coordination recommendations. The data collection process was conducted in person, and responses were analyzed using descriptive statistics and qualitative content analysis. Results: The results reveal that Portugal demonstrates higher productivity, stronger territorial coverage, and a more integrated inventory management system, while Brazil presents greater multidisciplinary team integration, more flexible fleet logistics, and more advanced digital health records. Despite these strengths, both countries continue to address key logistical aspects, such as scheduling, supply distribution, and data management, largely through empirical strategies. Conclusions: This research contributes to the theoretical understanding of international HHC logistics by emphasizing strategic and systemic aspects often overlooked in operational studies. In practical terms, it offers insights for public health managers to improve resource allocation, fleet coordination, and digital integration in aging societies.

1. Introduction

Given the demographic transition and growing demand for decentralized health care models, Home Health Care (HHC) has become a strategic tool to reduce hospitalization costs and ensure service continuity. However, these services present logistical complexities that vary significantly across countries and systems.

This study aims to answer the following research question: How do logistical structures and operations in HHC differ between Brazil and Portugal, and what performance indicators highlight inefficiencies or good practices in each context?

By comparing these two countries (culturally similar but structurally distinct), we explore how HHC logistics are managed and how these systems can be improved through targeted policy and operational changes.

Home health care (HHC) refers to the provision of services at patients’ homes by multidisciplinary teams consisting of nurses, physicians, physical therapists, and other health care professionals [1]. The concept of HHC has been formulated as a governmental strategy to mitigate the costs associated with hospitalization while simultaneously aiming to maintain or enhance the standard of health care services provided. Additionally, HHC services are generally favored by patients, if they are appropriate and recommended by physicians in comparison to conventional hospitalization methods [2]. These services enable a reduction in travel time between various appointments, allowing individuals to redirect this time toward prioritizing what is essential in their lives [3]. However, the implementation of HHC presents significant logistical challenges, especially in terms of team scheduling, fleet management, material supply, and information systems integration. These aspects are often overlooked in the literature, particularly in comparative international contexts.

According to the World Health Organization, the number of individuals aged >60 years is expected to increase from 841 million to 2 billion by the year 2050 [4]. Two factors contribute to this trend: a decrease in mortality rates (due to improvements in quality of life and advances in medicine) and low birth rates. This is particularly evident in the European continent, notably, in countries such as Sweden, Finland, Denmark, and Portugal. Consequently, the demand for HHC is on the rise in these countries, prompting local governments to explore ways to reduce costs associated with the health care sector. Both the life expectancy and the number of services provided for palliative care in these countriesincreased to 76 years. This increase in life expectancy is the result of investments in public policies by the State, including the implantation and implementation of the Unified Health System (UHS).

The first HHC service emerged in 1947 and developed further from the 1990s onward [5]. Furthermore, significant investments in HHC have been made over the years. For instance, over a two-year period (1997–1998), the Canadian government allocated approximately EUR 109 per capita to the sector. In 2001, the United States allocated approximately EUR 127 per capita [6]. Denmark allocated 1.6% of its GDP in 2005 (approximately EUR 3.52 billion) for the care of 200,000 users [7]. In 2016, the government of Hong Kong increased the annual budget for health care spending on individuals aged 70 or above to EUR 224 per capita [8]. In Portugal, between 2015 and 2017, approximately EUR 121 million were allocated to the National Integrated Continued Care Network (RNCCI) [9]. In Brazil, in 2015, investments in HHC were approximately EUR 69 million, representing 0.0042% of the GDP [10]. The number of individuals dependent on HHC services in Germany reached 1.6 million users in 2012, with a trend indicating an increase at that time [11].

In general, HHC has been gaining increasing prominence in the national health care services of developed countries, with the primary users being individuals over the age of 65. In developing countries, these types of services are more recent, and their progress has been slow due to economic challenges, corruption, uncontrolled population growth, lack of infrastructure and security, and persistent diseases such as dengue, yellow fever, and Zika virus, among others [12]. In some developed countries, these services are not yet a legal obligation, as is the case in Turkey [13].

The operational requirements for the effective functioning of HHC are substantial, as they involve issues at different decision-making levels: strategic, tactical, and operational. Given that this type of service is inherently linked to the field of logistics, it is crucial to engage in planning capable of addressing these types of issues, including routing, scheduling, inventory management, and districting [14]. For such problems, operational research models can be employed to find solutions and thus assist in decision-making, as has been effectively suggested in the recent scientific literature.

HHC has been extensively highlighted in the current literature, and various tools have been developed to improve its operation. However, there is a lack of scientific studies comparing the organizational structures and operations (and their respective performances) of HHC between developed and developing countries. Based on this, the present study aims to conduct a comparative analysis between the HHC systems of Brazil and Portugal, specifically focusing on approaches to various logistical challenges. This includes considerations of productivity indicators (number of users attended per year), types of care provided, team composition, costs, budgets, daily planning, fleet management, information records, and employed technologies.

Despite increasing attention to HHC in developed countries, there is still limited research comparing the logistical structures and performance of these services across different national contexts. Most existing works focus on tactical-level problems such as routing or scheduling, without addressing the broader strategic and organizational dimensions in a comparative framework.

This gap justifies a comparative analysis between the Portuguese and Brazilian HHC systems. These two countries offer an interesting contrast due to their cultural similarities, shared language, and distinct realities in the public health care sector. In both contexts, public sector services were implemented much later than in pioneering nations such as Sweden, Finland, and Denmark [7]. Additionally, both countries allocate significantly limited budgets to their respective health care services in comparison to those of countries like Canada, Denmark, and Germany.

Therefore, this study aims to answer the following research questions:

• How do logistical structures and operations in HHC differ between Brazil and Portugal?
• What performance indicators highlight inefficiencies or good practices in each context?
• How can these insights inform policy and operational improvements in public HHC delivery?

To address these questions, we conduct a comparative study based on qualitative and descriptive analyses of HHC systems in both countries. This paper is structured as follows: Section 2 presents the theoretical background; Section 3 describes the methodology; Section 4 discusses the results and findings; and Section 5 concludes with implications for theory and practice.

2. Research Methodology

The steps developed in the study to fulfill the general objective are presented in Figure 1.

As presented in Figure 1, after defining the general objective of the study, the subsequent steps involved determining the countries and municipalities to be considered. In this case, in addition to the similarities between the two countries (language, culture, among others), a small number of studies addressing home health services in each country were identified. The cities were selected based on the recommendation of the national manager of home health in each country, considering criteria such as productivity, workload, and service quality. Consequently, the necessary data to achieve the proposed objective were defined. The type of questionnaire and the questions were determined considering indicators related to the general characterization of services, required resources, planning, materials, and information recording. After obtaining favorable opinions from the ethics committees, the scheduling process began with the managers of each team and municipality. The application was conducted in person, and both quantitative and qualitative data were collected. These data were subsequently inputted and organized in Google Sheets and subsequently analyzed. The results are presented and discussed in this study.

2.1. Study Setting and Design

This study was applied in two countries: Portugal and Brazil. In Portugal, the tool was applied to four health center clusters, ACES (Cávado I, Cávado II, Cávado III, and Alto Ave), and in Brazil, it was applied to four municipalities (Blumenau, Curitiba, Uberaba, and Uberlândia).

The HHC services in Portugal were implemented within the scope of the National Integrated Continued Care Network (RNCCI). This network emerged with the proposal of filling the existing gap in this sector, aiming to position the country at the average (or higher) level of health care service provision among European Union (EU) countries. The RNCCI was established by Decree-Law No. 101/2006 and was developed by the Ministries of Health and Social Security. The primary objective of this network was to implement a health care delivery model tailored to the needs of citizens, where it would be possible to receive the necessary care at the right time and place from the most suitable provider [15].

The Groups of Health Centers (ACES) were created in 2008 and include various health units, such as Family Health Units (USFs), Personalized Healthcare Units (UCSPs), Public Health Units (USPs), Shared Care Resource Units (URAPs), and Community Care Units (UCCs) (Decree-Law No. 28/2008, February 2008). The ACES collaborate with the RNCCI through the UCC and provides health services through Integrated Continuous Care Teams (ECCI) and Community Support Teams for Palliative Care (ECSCP).

The ECCI or Portuguese HHC team is composed of a multidisciplinary team consisting of physicians, nurses, and social service technicians. In addition to these professionals, the team may also include other specialists, such as nutritionists, psychologists, and physiotherapists, who are typically shared resources among the ACES. According to the Annual Monitoring Report of the RNCCI in 2015, 286 ECCI teams were distributed throughout the country.

In 2017, there were approximately 6585 available vacancies in the ECCI, 25% of which were concentrated in the northern region, 16% in the central region, 32% in the Lisbon and Vale do Tejo region, 8% in the Alentejo region, and 18% in the Algarve region. Among all users covered by the RNCCI services in 2015, approximately 84% were aged older than 65 years, and 47% were aged older than 80 years. This highlights the significance of these services, particularly for countries facing an aging population, such as Portugal, where 19% (approximately 2.01 million people) are aged 65 or older [16].

In the Portuguese case, only ACES under the responsibility of the Northern Regional Health Administration (ARS Norte) were selected. This region consists of a total of 24 ACES, 87 ECCI, and two support warehouses. The Maia and Vila Real warehouses are responsible for supplying all the necessary materials for the execution of HHC in the jurisdictional area of the Northern Regional Health Administration (ARS Norte). Requests for materials and consumables are typically made monthly through a logistics computer system and are delivered by the warehouse team on a designated date. In cases of urgency, extraordinary requests are usually accepted to prevent care delivery failures due to a lack of materials. The ECCI in this region typically has a total of 20 vacancies for user registration and an average occupancy rate of 70.1% [17]. For the present study, 4 ACES were selected: Cávado I, Cávado II, Cávado III, and Alto Ave (Figure 2).

As its area of influence, ACES Cávado I has the municipality of Braga, which comprises three ECCI teams: Carandá, Infias, and Maximinos. The ACES Cávado II, also known as Gerês-Cabreira, encompasses the health centers in the municipalities of Amares, Póvoa de Lanhoso, Terras de Bouro, Vila Verde, and Vieira do Minho. The health centers of Barcelos, Barcelinhos, and Esposende are part of ACES Cávado III. In this ACES, there are three ECCIs, two in the municipality of Barcelos (Barcelos and Barcelinhos) and one in Esposende. The ACES Alto Ave Health Center covers the municipalities of Mondim de Basto, Fafe, Cabeceiras de Basto, Guimarães, and Vizela. However, for the current study, only the ECCIs of Guimarães and Taipas, both located in the municipality of Guimarães, were considered.

In Brazil, these services expanded nationally starting in the 1990s (primarily through private institutions) and were only integrated into the public health system in 2013 [18]. HHC services in the Brazilian public system are provided through the Better at Home Program (BHP). The HHC represents a modality of health care that is either substitutive or complementary to existing services. It is characterized by a set of actions related to health promotion, disease prevention, treatment, and rehabilitation and is delivered at home, ensuring continuity of care and integration into health care networks [19].

The management of this program falls under the municipal scope, meaning that each municipality is responsible for managing its own subsystem. However, a portion of the funds required for the teams’ operation is provided by the federal government. The annual budget allocated by the federal government for each type of EMAD 1 (multidisciplinary HHC team) is EUR 13,850 per month, EUR 9418 per month for type EMAD 2, and EUR 1662 per month for EMAP (multidisciplinary support team). These amounts are transferred monthly from the National Health Fund to the health fund of the beneficiary city, contingent upon the fulfillment of certain requirements outlined in [19].

The services offered by the program are divided into three modalities: AD1, AD2, and AD3. The AD1 modality is for users who require less complex care, who typically receive monthly visits from basic care teams and may be supported by Family Health Support Centers [20]. The AD2 modality is intended for users in need of more complex care that can be provided in their own homes, such as wound care, rehabilitation, and postoperative home care. In the AD3 modality, users requiring high-complexity care that involves continuous monitoring and the use of equipment are included [20].

The EMAD and EMAP are responsible for providing care via these two modalities (AD2 and AD3). The types of services provided by EMAD and EMAP are available in municipalities with a population equal to or greater than 40 thousand inhabitants, classified as EMAD type 1, and in municipalities with a population between 20 and 40 thousand inhabitants, either individually or in a group of municipalities with a population equal to or greater than 20 thousand people, classified as EMAD type 2. In addition to population factors, it is necessary for these municipalities to have an available mobile emergency care service (SAMU) and a reference hospital. The EMAD is responsible for serving a population of up to 100 thousand people, with the support of the EMAP if necessary [20]. Given that the EMAP is a support team, the home care areas were divided based on the number of EMADs. Currently, the BHP covers 340 municipalities, with a total of 598 EMADs spread across the nation. Notably, the majority of EMADs are located in cities with a high number of people aged 65 or older, such as in some capitals, such as São Paulo-SP, Belo Horizonte-MG, and Porto Alegre-RS, where each city has more than 10 EMAD teams.

However, there are regions with high numbers of people in this age group who do not have teams, such as in some cities in the interior of the state of São Paulo, in the state of Pará, in the border region between Argentina and Uruguay, and in the capitals of the states of Espírito Santo and Roraima (the only states not covered by the program). In the Brazilian context, four different cities (Blumenau, Curitiba, Uberaba, and Uberlândia) were selected, comprising a total of 18 EMAD teams, as depicted in the map (Figure 3).

The city of Blumenau is situated in the state of Santa Catarina, southern Brazil, and is equipped with 3 EMADs and 1 EMAP. The city of Curitiba is the capital of the state of Paraná, which is also situated in the southern region of Brazil and is equipped with 8 EMAD teams and 3 EMAP teams. The city of Uberaba, located in the state of Minas Gerais in the southeastern region of Brazil, features 2 EMAD teams and 1 EMAP team. The city of Uberlândia, located in the state of Minas Gerais, has 7 EMAD teams and 3 EMAP teams, but only 5 EMAD teams were considered.

The choice of regions in Portugal and Brazil was not random. It followed the recommendation of each country’s national coordinator for HHC, considering factors such as service performance, geographic diversity, and access to reliable data. In the Portuguese case, the northern ACES were selected because they have more structured logistics and are closely integrated into the RNCCI, which made it easier to understand how more consolidated models work in practice. In Brazil, the selected municipalities are located in areas with higher population density and strong participation in the Better at Home Program. These locations also reflect a wide range of team configurations, fleet strategies, and care routines. This combination allowed us to compare different realities while still keeping the focus on what both systems are trying to solve from a logistical point of view.

2.2. Data Collection

For this study, a semi-structured survey was developed for the data collection process involving team managers. The choice of a semi-structured survey is directly related to the central objectives of the study. This type of survey was created based on a script of open-ended questions, allowing for the inclusion of additional questions when deemed necessary.

Additionally, a maximum duration of 60 min was set for each interview. Furthermore, participants were requested to electronically submit a list of necessary data, with a deadline of at least 30 days before the scheduled interview date. Initially, the obtained data (both quantitative and qualitative) were used to compare the two home health care systems and address zoning issues in both cases, as described in the central objectives of the paper. In the Brazilian case, 4 municipalities (cities) located in the southern and southeastern regions of the country were selected. In the Portuguese case, 9 municipalities from the northern region were chosen. The greater number of selected municipalities in the Portuguese case is because, in general, they have fewer teams per municipality than does the Brazilian case.

To develop this study, ethics committee reviews (ECRs) were obtained from the following institutions: the Health Ethics Committee of ARS Norte (ECR n° 61/2017), the Ethics Subcommittee for Social and Human Sciences of the University of Minho (SECSH 011/2017), the Brazilian Research Ethics Committee (ECR n° 2036.584), and the Research Ethics Committee of the city of Curitiba (ECR n° 37/2017).

3. Results and Discussion

The Brazilian and Portuguese cases analyzed in this study exhibited significant differences in the operations of HHC in their municipalities and cities, primarily due to variations in territorial and geographical aspects, population and demographic characteristics, and organizational structures. A comparison between these two countries was conducted based on parameters related to organizational structure and case management, team composition, facilities and districting plans, fleet management, supply management, patient admission process, productivity, and budgets. These parameters were defined using data related to service management obtained through a semi-structured questionnaire.

3.1. Organizational Structure and Management

Some differences were found between the Brazilian and Portuguese cases in terms of organizational structure and management. In Portugal, the ECCI, integrated into the RNCCI, operates under three levels of coordination: local (ACES), regional (ARS), and national. The management of each team is typically overseen by the coordinator of the UCC or the local health center. Additionally, each team has a lead nurse responsible for assisting the coordinator in decision-making. Currently, almost all the 278 municipalities in Continental Portugal are covered by HHC services. In each municipality, there is at least one ECCI, except for 54 municipalities.

In Brazil, the teams respond solely to the municipal councils of each city but are also monitored by national coordination. The teams in each city are managed by a single administrator. Like in Portugal, each team has a leader who is responsible for assisting the administrator in decision-making. Cities intending to implement an EMAD must have a minimum population of 40,000 inhabitants, and other requirements, such as the existence of a mobile emergency care service and a reference hospital, are necessary, as per Decree N° 825/2016. According to information provided by the national coordinator of the BHP, approximately 320 new HHC teams are currently awaiting financial resources for their implementation. This is due to the financial crisis faced by Brazil since 2015, which led to a significant reduction in resources from the National Health Fund, at least concerning the funds provided by authorities for the analyzed health subsystem.

3.2. Team Composition

The team composition and the types of care provided in both countries differ when compared. When analyzing the teams in both countries, a significant difference in the percentage of weekly workload between nurses and other professionals can be identified in Figure 4 and Figure 5.

This is due to two factors. First, nurses in Portugal, unlike those in Brazil, are qualified to perform a wider range of care tasks due to the specificity of their training. For example, nurses with a specialization in rehabilitation provide both nursing and physiotherapy care. In all the teams analyzed in the Portuguese case, only the ECCI in Guimarães had a physiotherapist available for the provision of HHC. The second factor is related to the fact that most of the care provided by ECCI is provided by nurses.

Based on the obtained data, an ECCI has, on average, 165 h per week of available workload for a total of 20 patients. However, only five of these hours are allocated for medical care (typically used in multidisciplinary visits), and the physician has the lowest workload on the team, as discussed in Filipe [21]. Additionally, the weekly workload of nurses in ACES Cávado II was lower than that in the other ECCIs analyzed, which can be explained by the inclusion of an operational assistant (with a workload similar to that of a nurse): this professional is responsible for driving vehicles and assisting health care professionals in some procedures, such as preparing bags of clinical and pharmaceutical materials.

In Brazil, the constitution of teams is determined based on Ordinance No. 825/2016 of the Ministry of Health, which establishes the minimum number of weekly hours per type of professional for each type of team. On average, an EMAD has approximately 242 h per week available for the care of a total of 60 users.

However, the average percentage of hours worked by nurses on the analyzed teams in Brazil (74%) was lower than that in the Portuguese case (79%). This is because the workload of other professionals (e.g., physiotherapists and doctors) is greater in the Brazilian context. Additionally, EMAD teams in Brazil include other professionals, such as nursing technicians and physiotherapists. In contrast to Portuguese ECCIs, rehabilitation care in Brazil is typically provided by physiotherapists. Furthermore, in addition to participating in multidisciplinary visits (such as in Portugal), physicians also perform some less complex procedures.

3.3. Facilities and Fleet Management

The facilities or operational bases utilized by the teams in both countries are typically located in health centers, hospitals, and universities. In these locations, there is usually a meeting room, an office for the coordinator, a small warehouse for clinical and pharmaceutical products, and a room with computers for information recording. In Portugal, each team has its own facilities, in contrast to Brazil, where the facilities are shared among all teams within a specific municipality.

Fleet management for the teams in Portugal is overseen by the Management Support Unit (UAG) of each health center or UCC. The vehicle fleet is typically owned and shared with professionals from the UCC. Nurses are generally responsible for driving and refueling vehicles (using a corporate card), except for ECCIs, which have operational assistance on their staff. Vehicle maintenance is conducted on a corrective basis; in other words, nurses report a potential mechanical issue to the UAG, and the vehicle is promptly assessed by the UAG technician and, if necessary, referred to a specialized automotive maintenance company. Vehicles undergoing maintenance are usually replaced by other vehicles from the UCC or ACES fleet when available; in cases of unavailability, temporary taxi services are contracted.

In Brazil, in most of the analyzed cities, the vehicle fleet is outsourced, except for Uberaba, which has a fleet management system similar to that of the Portuguese case. These vehicles are typically leased to local cooperatives or rental car companies. In some cases, drivers are included in rental services, such as in the cities of Uberlândia and Curitiba. Maintenance services and vehicle refueling are generally managed by a leasing company or cooperative, except for the city of Blumenau, which directly covers fuel expenses. Vehicles with maintenance issues or those reaching a certain mileage are replaced by others of the same category through immediate hiring.

3.4. Materials Management

In Portugal, the clinical and pharmaceutical materials of the analyzed ECCIs belonging to the ARS Norte region were purchased and distributed by warehouses in the cities of Maia and Vila Real. For each team, a professional was responsible for recording material consumption and placing the monthly order through the computerized inventory management system of the ARS Norte. Consequently, these orders are typically delivered alongside materials requested by the UCC or health center on a specific date. In the event of unexpected material shortages or operational issues, extraordinary orders are processed and delivered based on the urgency of the team’s needs. Additionally, there are instances where teams utilize materials borrowed from health centers, UCCs, or even other ECCIs within the local ACES.

In Brazil, clinical and pharmaceutical materials are generally acquired by pharmaceutical supply centers or hospitals and subsequently distributed by teams, as in Portugal. However, not all cities have a computerized inventory management system. In some cases, orders are requested via email or telephone. Deliveries are typically handled by local carriers, or the team coordinates with the driver for the picking up of materials directly from the warehouse. Inventory management is typically carried out by a local manager or by an administrative assistant who is part of the team’s staff.

3.5. Operations and Productivity of Teams

In Portugal, HHC teams typically establish weekly schedules with the assistance of local coordinators and nurses in charge of the team. Material kits for each visit will be prepared daily by the nurses themselves or by operational assistants. Nurses use different criteria to determine the order of patients to be visited, but typically, the first criterion considered is the patient’s needs, followed by the distance to be covered. Vehicles are generally shared among all team members, who plan their daily visits based on the delivery and collection schedules of other professionals. Visits are usually made by two nurses. At the end of visits, during lunch breaks, or at the end of the workday, nurses return to their facilities, record the mileage covered, and document information regarding the care provided during the day. The mileage is recorded in a document kept in the vehicle and is collected by the UAG at the end of a specific period. Information related to the care provided is recorded via two computer systems.

This information is recorded daily in the S-Clínico system. However, it is also necessary to register information biweekly in a second system, the GESTCARE^®CCI, which is an RNCCI system used by all team members to record clinical indicator production.

The scheduling of patients for Brazilian HHC teams is developed collaboratively among the responsible nurses of each team and the local manager. During visits, a nurse or doctor prescribes the list of materials needed for a specific period, and the pharmaceutical warehouse team delivers them to the patient’s home. Consequently, professionals typically carry only briefcases containing additional materials for unforeseen situations during their visits. The order in which patients are attended to (routing) is usually determined by the driver and the health care professional in charge of the team (either a nurse or doctor). Typically, the professionals present in the vehicle provide care to the same patient. This sub-team consists of professionals, such as a doctor, nurse, or physiotherapist, accompanied by one or two nursing technicians (with two to three professionals per vehicle). In Curitiba, since vehicles can accommodate up to nine workers, during admission or multidisciplinary visits, and in special cases, all team members participate in home visits.

Upon returning from visits, team members typically record information in the e-SUS system. However, some teams have developed a physical form that is completed during the visit and later handed over to an administrative assistant for input into the computer system. In the city of Blumenau, the recording of this information is carried out using tablets. This e-SUS system is an important tool for data collection.

3.6. Team Productivity

The productivity indices of each ECCI in Portugal are presented in

Table 1. The monthly productivity of Portuguese teams.

ACES	HHC Teams	Workload (Hours/Month)	Number of Visits/Month	Hours/Visit
Alto Ave	Guimarães	1004	296	3.39
	Taipas	260	80	3.26
Cávado I	Braga—Carandá	668	201	3.33
	Braga—Infias	542	192	2.83
	Braga—Maximinos	638	164	3.89
Cávado II	Amares	564	73	7.73
	Póvoa do Lanhoso	640	43	14.89
	Terras de Bouro	529	65	8.15
	Vieira do Minho	623	127	4.9
	Vila Verde	833	165	5.05
Cávado III	Barcelinhos	677	113	5.99
	Barcelos	855	213	4.01
	Esposende	942	151	6.24

.

Based on the data obtained from the Brazilian teams, the productivity indicators were also organized and synthesized (

Table 2. The monthly productivity of Brazilian teams.

Cities	HHC Teams	Workload (Hours/Month)	Number of Visits/Month	Hours/Visit
Blumenau	HHC 1	1042	68	15.32
	HHC 2	1042	93	10.20
	HHC 3	1042	162	6.43
Curitiba	HHC 1	1085	68	15.96
	HHC 2	1085	183	5.93
	HHC 3	1085	57	19.04
	HHC 4	1085	51	21.27
	HHC 6	1085	176	6.16
	HHC 7	1085	152	7.14
	HHC 8	1085	130	8.35
	HHC 9	1085	150	7.23
Uberaba	HHC A	737.80	135	5.47
	HHC B	1042	162	6.43
Uberlândia	Center HHC	1020	264	3.86
	East HHC	1020	272	3.75
	North HHC	1020	206	4.95
	West HHC	1020	197	5.18
	Southern HHC	1020	246	4.15

).

Table 2 shows that the workload, in most cases, is similar among teams within the same city. This demonstrates that the compositions of these teams have been managed as required by Ordinance No. 825/2016 of the Ministry of Health. Additionally, the workloads of Brazilian teams are higher than those of the teams analyzed in the Portuguese case.

Upon correlating the indicators between Brazil and Portugal, it is concluded that the European country achieved the best productivity indices, with an average of 5.67 h per visit. However, some ECCIs in Portugal have been facing operational problems, as discussed earlier, which have adversely affected the performance of these teams. The average productivity index of Brazilian teams remained at 8.77 h per visit. This may reflect the inefficient utilization of professionals or may be associated with extended travel time between users due to the traffic congestion typically encountered in Brazilian cities.

3.7. Costs and Budgets Allocated to the HHC Teams

In Portugal, as ECCIs are included in the RNCCI, the budget available for the operation of HHC is part of the joint budget for these services with other network services. For this reason, it was not possible to obtain values specifically allocated to ECCIs. However, between 2015 and 2017, approximately EUR 121 million were allocated to the entire health care network over a period of 3 years [17]. According to the same source, in the year 2018, the ARS Norte invested approximately EUR 49 million to include an additional 2655 inpatient beds and 1653 new positions in ECCIs. The average daily cost of HHC services is approximately EUR 23.07 per day, according to the data obtained in the present study.

The BHP (Brazil) has recorded variable annual budgets, depending on the quantity and number of teams. Type 1 EMADs receive EUR 166,205 each; Type 2 EMADs receive EUR 133,019; and EMAPs receive EUR 19,945 per year. In 2017, approximately EUR 101 million were allocated for the joint funding of the 598 EMADs (types 1 and 2) and the 323 EMAPs distributed throughout the country. According to information provided by local managers, these ‘federal transfers’ are not sufficient to keep the teams operational for twelve months. Consequently, municipal councils need to cover their respective deficits in federal funding. The daily cost of HHC services in Brazil is approximately EUR 17.96, according to the data obtained from the teams.

3.8. Best Practices

The best practices (strengths) related to the services in both cases were identified to summarize the comparisons between them (

Table 3. A comparison between HHC services in Portugal and Brazil.

Indicators	Best Practices Pertaining (Preferably in the Highlighted Case)
	Portugal	Brazil
Workload of other types of professionals
Territorial coverage of services
Distance traveled
Multidisciplinary team
Fleet management
Integration among teams
Inventory management
Number of patient slots
Annual budget
Productivity
Information recording

).

Table 3 was developed based on the data provided by local managers of each HHC team in both countries within the scope of this study. In Portugal, productivity (number of available working hours per team) is more efficiently utilized than in Brazil, even considering that the travel time for EMADs is greater than that for ECCIs. Inventory management in Portugal also appears to be more organized, with two warehouses and a unique logistics system for all ECCIs in the northern region of the country. In Brazil, inventory management information systems are not integrated at the regional, state, or national levels.

In Portugal, the territorial coverage of HHC services extends to most of the country, with few municipalities lacking this service. In contrast, in Brazil, only 6% of all cities have this type of service (representing approximately 25% of the Brazilian population). The distance traveled between team facilities in the Portuguese case and the service area is shorter than that in the Brazilian case, as each ECCI has its own facility, typically located within its service territory. In Brazil, since facilities are usually shared, in some cases, long distances from facilities to service areas must be covered. Finally, the annual budget provided by the Portuguese state is sufficient to keep the ECCIs operational without the need for financial assistance from municipal authorities, unlike in Brazil.

When comparing Brazilian HHC services with those of the Portuguese population, good practices are related to the existence of multidisciplinary teams, fleet management, information recording, the absence of waiting lists, and integration among teams. Brazilian home health services exhibit greater multidisciplinary power, as there are other types of professionals with a workload similar to that of nurses, in addition to EMAP teams supporting EMAD teams. In Portugal, other types of professionals have a lower weekly workload than nurses, as also discussed in [21]. Fleet management also seems to be better handled by Brazilian teams, with features such as drivers for most of the cities analyzed and a larger number of available vehicles. Additionally, in cases of mechanical issues, vehicles are immediately replaced. In Portugal, cases of vehicle shortages were recorded, forcing teams to use taxi services for care provision. In [21], insufficient vehicles for HHC teams were also identified as a weakness in Portuguese HHC.

In Brazil, there is only one information recording system, e-SUS, unlike in Portugal, where the use of two systems is necessary, generating information duplication and consuming more professional workload time. Additionally, in some Brazilian cities, tablets are already used for information recording during visits. The number of slots in EMADs (60 slots) is greater than that in ECCIs (usually 20 slots), thus reducing the possibility of waiting lists, as observed in some municipalities in Portugal. Since Brazilian teams in a particular city share the same facilities, this allows for greater daily integration. In Portugal, this type of integration does not occur daily and occurs only during meetings or gatherings of a particular ACES.

4. Lessons from the Pandemic: Strengthening Home Health Care Logistics

The COVID-19 pandemic brought renewed attention to the strategic role of logistics in health care delivery, especially in decentralized models such as Home Health Care (HHC). The rapid spread of the virus demanded agile responses, decentralized resource management, and new routing strategies to minimize risk and ensure care continuity.

During the pandemic, home-based care proved to be a safe and cost-effective alternative to hospital-centered models, particularly for elderly and chronically ill patients. However, logistical bottlenecks—including limited vehicle fleets, fragmented inventory systems, and data integration failures—were exposed in many national systems [3,22].

Several studies have since emphasized the importance of integrated supply chains, digital platforms, and predictive scheduling algorithms for resilient HHC delivery [13,23]. These findings suggest that logistics in HHC must be viewed not merely as an operational concern but as a vital element of public health strategy, particularly in the face of future crises.

This reinforces the relevance of international comparative studies, like the present work, that investigate how distinct systems structure their care delivery. Understanding the successes and failures during the pandemic provides valuable input for enhancing HHC logistics under normal and emergency conditions alike.

5. Conclusions

5.1. Key Conclusions

This study provided a comparative perspective on the logistics of Home Health Care (HHC) services in Portugal and Brazil, highlighting how differences in territorial organization, team configuration, and infrastructure impact service delivery. In Portugal, the system benefits from higher productivity, broader territorial coverage, and more structured inventory management. In contrast, Brazilian teams show greater multidisciplinary integration, more flexible fleet logistics, and notable advances in digital health information systems.

Despite these strengths, both countries must still address many logistical aspects empirically, particularly in scheduling, materials distribution, and daily operations. These findings reinforce the need for more structured planning and the use of analytical tools to support logistics in home-based health care.

5.2. Contributions to Theory

Theoretically, this study contributes to a broader understanding of HHC logistics by moving beyond common operational issues, such as routing and scheduling, to examine strategic and systemic aspects in a cross-country setting. While Portugal and Brazil share linguistic and cultural similarities, their institutional and logistical frameworks differ significantly.

This research offers a multilevel approach to understanding HHC delivery, emphasizing the interactions between national policy, regional coordination, and frontline team dynamics. These findings align with the recent literature addressing scheduling complexities and interdependent health care logistics [7,11].

5.3. Managerial Implications

For health care managers and policymakers, the results suggest several actionable directions. In Portugal, diversifying the workload through broader inclusion of non-nursing specialists may enhance efficiency. In Brazil, greater investments in permanent facilities and inventory control systems could lead to measurable gains in service quality.

Digital integration also emerges as a priority. Streamlining patient records into a unified platform and enabling mobile data entry would reduce duplicated tasks and allow professionals to dedicate more time to care delivery. This is particularly relevant in contexts where staff face high demands and operate across wide territories.

Managers in both countries can also benefit from adapting successful tools, such as visit clustering methods, territory planning algorithms, and structured fleet coordination models [6,8].

Furthermore, the international experiences analyzed may provide relevant insights to broaden the debate on public policies aimed at home health care, as well as on logistics and team management, similar to what has been identified in urban contexts within the fields of transport engineering and public infrastructure [24].