UHC Sustainability via Reform Capability: Portugal’s 50-Year Health System Evolution

Abstract Background Universal Health Coverage (UHC) sustainability in high-income countries faces mounting pressures from demographic shifts, fiscal constraints, and global crises. Traditional frameworks emphasizing coverage, access, and financial protection inadequately address adaptability needs. Portugal's 50-year primary care reform offers insights into how dynamic reform capabilities sustain UHC. Methods This case study (1974-2024) applies Kingdon's Multiple Streams Framework to analyze Portugal's reform capability evolution across three stages: Foundational (1974-2004), Integrative (2005-2014), and Transformative (2015-2024). Sources include policy documents, legislation, academic literature, and performance indicators. Reform capability was assessed through technical, political, administrative, and adaptive dimensions. Results Portugal's incrementally maturing reform capability enabled resilience and innovation. Foundational reforms established universal access despite implementation gaps. Integrative reforms, particularly Family Health Units, improved chronic care management by 35%, preserved 85% of services during austerity, and enhanced satisfaction by 40%. The Transformative stage achieved rapid digital adoption (85% of units digitized within three months during COVID-19), integrated care pathways, and multi-sectoral governance, reducing avoidable hospitalizations by 30% while outperforming EU benchmarks at lower cost. Conclusions This study introduces the Reform Capability Maturity Model, redefining UHC sustainability as continuous capability-building. Portugal demonstrates that UHC requires iterative development of technical, political, and adaptive capacities to navigate crises and deliver value. These findings offer actionable strategies for health systems confronting aging populations, fiscal constraints, and emerging threats. Key messages • Reform capability - technical, political, and adaptive capacities - determines UHC sustainability. Portugal’s 50-year evolution shows iterative capability-building enables resilience even in crises. • Reform capability - the multidimensional capacity to design, implement, and adapt health system changes - is the critical determinant of UHC sustainability in high-income countries.