Abstract

Presentation

The authors are members of the research project entitled “Analysis of the effectiveness of the Mais Médicos (More Doctors) initiative to ensure the universal right to health care,” who felt under obligation to issue an Opinion to refute the arguments put forward by Ribeiro¹1. Ribeiro RC. Programa Mais Médicos - um equívoco conceitual.Cien Saude Colet 2015; 20(2):421-424., who declared that the Program was a conceptual error. Based on evidence found in the initial field research experiences, it is argued that the More Doctors Program is an effective way to reduce health iniquities in Brazil.

This article is divided into six sections: i) Presentation; ii) Reasons for implementing the More Doctors Program, which discusses conceptual questions related to health iniquities and the epidemiological transition; iii) Regional inequalities in the supply of doctors in Brazil; iv) Providing doctors: evidence of the contribution that this Program has made to reduce the iniquity in the supply of doctors; v) Investments in professional training and in the Basic Health Units; and vi) Final considerations.

Reasons for implementing the Mais Medicos (More Doctors) Program

The social determinants of health are the social conditions in which people live and work, which indicate both the specific characteristics of the social context affecting health, as well as the way that these conditions translate this impact on health. In the views of Solar and Irwin²2. Solar O, Irwin A. Rumo a um modelo conceitual para análise e ação sobre os Determinantes Sociais de Saúde. Ensaio apresentado a Comissão de Determinantes Sociais em Saúde. Genebra: OMS; 2005., social determinants in health need to be subjected to a value assessment.

Iniquities in health involve a good deal more than mere inequalities and imply a failure to avoid or overcome such inequalities which infringe the precepts of human rights, or are unjust; they are rooted in social stratification³3. Evans T, Whitehead M, Diderischsen F, Bhuiya A, Wirth M.Challenging inequities in health from ethics to action. NewYork: Oxford University Press; 2001.^,44. Graham H, Kelly MP. Health inequalities: concepts, frameworks and policy. London: Health Development Agency; 2004. (NHS Briefing Paper).. The lack of access to extensive primary health care affects a large sector of the Brazilian population living in remote areas, which are difficult to reach, and in the suburbs of major cities. In these situations, the Family Health Teams (FHT) were composed of nurses, nursing technicians and community health agents and did not include a trained physician, which limited their ability to provide comprehensive health care.

Almeida Filho⁵5. Almeida Filho N. O que é saúde? Coleção Temas em Saúde. Rio de Janeiro: Fiocruz; 2011. states that it is necessary to mobilize political support in order to promote equality in diversity, in order to reduce the role played by gender, age, ethnic-racial, cultural and social class differences as a means to determine economic, social and health inequalities, injustices and iniquities. Tackling the social determinates of health requires that action is taken involving structural and environmental causal processes⁶6. Nogueira RP. A determinação objetal da doença. In: Nogueira RP, organizador. Determinação Social da Saúde e Reforma Sanitária.Rio de Janeiro: Cebes; 2010. p. 135-150.^,77. Breilh J. Las tres ‘S’ de la determinación de la vida; 10 tesis hacia una visión crítica de la determinación social de la vida y la salud. In: Nogueira RP, organizador. Determinação Social da Saúde e Reforma Sanitária. Rio de Janeiro: Cebes; 2010. p. 87-125, which include the organization of health services, among which access to medical care is a central issue in order to guarantee comprehensive health care.

Another important aspect to be considered is the aging of the Brazilian population and the subsequent changes in its epidemiological profile, which reveal the need to redesign health care. The old hospital-centric model needs to move towards Primary Health Care (PHC) guaranteeing resources for integrated health care and protection.

The involvement of physicians in the FHTs builds up and enhances the ability of these groups to provide care, especially from the standpoint of adopting a model of health care that includes the different health promotion requirements, the prevention, diagnosis and treatment of diseases, prioritized for the territory, as well as providing diagnoses and treatment in a comprehensive manner. In this way, the SUS will be able to face the challenges imposed by the present epidemiological transition phase, namely, the double burden of disease: obesity and chronic non communicable diseases, on the one hand, and infectious and parasitic diseases, as well as lingering malnutrition, on the other.

Chronic non-communicable diseases (NCDs) have become one of the main health priorities in Brazil. Although a slight annual decrease has been noted in respect of the prevalence of NCDs, 74% of all deaths in Brazil were attributed to these diseases in 2012⁸8. Brasil. Ministério da Saúde (MS). Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas Não Transmissíveis (DCNT) no Brasil. Brasília: MS; 2011.^,99. Schmidt MI, Duncan BB, Silva GA, Menezes AM, Monteiro CA, Barreto SM, Chor D, Menezes PR. Chronic non-communicable diseases in Brazil: burden and current challenges. Lancet 2011; 377(9781):1949-1961.. The reductions occurred, above all, in chronic respiratory and cardiovascular diseases, unequally distributed among the different social classes; such a positive outcome is attributed to the success of the health policies that led to a reduction in smoking and improved access to the Primary Health Care (PHC)⁹9. Schmidt MI, Duncan BB, Silva GA, Menezes AM, Monteiro CA, Barreto SM, Chor D, Menezes PR. Chronic non-communicable diseases in Brazil: burden and current challenges. Lancet 2011; 377(9781):1949-1961. units.

The increase in chronic NCDs has been linked to a nutritional transition, resulting from the adoption of non-healthy lifestyles, marked by sedentary habits and the excessive intake of industrialized and high calorie foods in people’s diets. And it is via the PHC that excessive weight gain and obesity increasingly feature in the statistics of morbidities in the population treated by the health teams¹⁰10. Jaime PC, Santos LMP. Transição nutricional e a organização do cuidado em alimentação e nutrição na Atenção Básica em saúde. Divulg. saúde debate 2014; 51:72-85. This has been corroborated by the Brazilian Ministry of Health, which launched the 2011 – 2022⁸8. Brasil. Ministério da Saúde (MS). Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas Não Transmissíveis (DCNT) no Brasil. Brasília: MS; 2011. Strategic Action Plan to Combat Chronic Non-Communicable Diseases in 2011. Based on a multi-sectorial and interdisciplinary approach, among other actions, the plan proposes to implement more programs directed towards promoting a healthy lifestyle implemented within the scope of PHC¹⁰10. Jaime PC, Santos LMP. Transição nutricional e a organização do cuidado em alimentação e nutrição na Atenção Básica em saúde. Divulg. saúde debate 2014; 51:72-85.

Regional inequalities in the supply of doctors in Brazil

The concentration of health professionals, especially physicians, in the great urban centers, is a problem that affects most countries. International experiences with regards to how to retain healthcare professionals in areas of vulnerability includes a series of strategies, ranging from methods to provide incentives to enforcement, such as selection, education, mandatory civil service, regulations, incentives and support¹¹11. Wilson NW, Couper ID, De Vries E, Reid S, Fish T, Marais BJ. A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. Rural Remote Health2009; 9(2):1060.^,1212. Dolea C, Stormont L, Braichet JM. Evaluated strategies to increase attraction and retention of health workers in remote and rural areas.Bull World Health Organ 2010; 88(5):379-385.. Most of these strategies are in accordance to those proposed by the World Health Organization with the aim of improving the retention of health workers in remote and rural areas¹³13. Rourke J. WHO Recommendations to improve retention of rural and remote health workers - important for all countries. Rural Remote Health2010; 10(4):1654..

Evidence reveals marked inequalities in Brazil related to access to medical care among the inhabitants of different regions of the country¹⁴14. Tomasi E, Fachini LA, Thumé E, Piccini RX, Osorio A, Silveira DS, Siqueira FV, Teixeira VA, Dilélio AS, Maia MFS. Características da utilização de serviços de atenção básica à saúde nas regiões Sul e Nordeste do Brasil: diferenças por modelo de atenção. Cien Saude Colet 2011; 16(11):4395-4404.^,1515. Campos FE, Machado MH, Girardi SN. A fixação de profissionais de saúde em regiões de necessidades. Divulg. saúde debate 2009; (44):13-24.. The Market Signs Research Station (Estação de Pesquisa de Sinais de Mercado – EPSM/UFMG) has developed a Scale of Health Professional Shortage Areas (HPSA) in Primary Health Care¹⁶16. Estação de Pesquisa de Sinais de Mercado (EPSM). Construção do índice de escassez de profissionais de saúde para apoio à Política Nacional de Promoção da Segurança Assistencial em Saúde. Belo Horizonte: EPSM/NESCON/FM/UFMG; 2010 [acessado 2015 set 29]. Disponível em: https://www.nescon.medicina.ufmg.br/biblioteca/imagem/2443.pdf
https://www.nescon.medicina.ufmg.br/bibl... , which showed that the Northern and Northeastern regions of the country were the worst affected by a serious shortage of doctors in 2012¹⁷17. Estação de Pesquisa de Sinais de Mercado (EPSM).Identificação de Áreas de Escassez de Recursos Humanos em Saúde no Brasil. Belo Horizonte: EPSM/NESCON/FM/UFMG; 2012 [acessado 2015 set 29]. Disponível em: http://epsm.nescon.medicina.ufmg.br/epsm/Relate_Pesquisa/Identifica%C3%A7%C3%A3o%20de%20%C3%A1reas%20de%20escassez%20de%20RHS%20no%20Brasil.pdf
http://epsm.nescon.medicina.ufmg.br/epsm... . The disparities were also extreme when comparing the availability of physicians in capital cities with the interior of the different states¹⁶16. Estação de Pesquisa de Sinais de Mercado (EPSM). Construção do índice de escassez de profissionais de saúde para apoio à Política Nacional de Promoção da Segurança Assistencial em Saúde. Belo Horizonte: EPSM/NESCON/FM/UFMG; 2010 [acessado 2015 set 29]. Disponível em: https://www.nescon.medicina.ufmg.br/biblioteca/imagem/2443.pdf
https://www.nescon.medicina.ufmg.br/bibl... ^,1717. Estação de Pesquisa de Sinais de Mercado (EPSM).Identificação de Áreas de Escassez de Recursos Humanos em Saúde no Brasil. Belo Horizonte: EPSM/NESCON/FM/UFMG; 2012 [acessado 2015 set 29]. Disponível em: http://epsm.nescon.medicina.ufmg.br/epsm/Relate_Pesquisa/Identifica%C3%A7%C3%A3o%20de%20%C3%A1reas%20de%20escassez%20de%20RHS%20no%20Brasil.pdf
http://epsm.nescon.medicina.ufmg.br/epsm... .

Another challenge faced when organizing PHC in Brazilian municipalities is the high turnover of health professionals, especially of team doctors. This fact jeopardizes the implementation of the longitudinal and ongoing health care of the user, a practice that is of fundamental importance for the prevention and treatment of chronic diseases¹⁸18. Campos CVA, Malik AM. Satisfação no trabalho e rotatividade dos médicos do programa de saúde da família. Rev Adm Pública 2008; 42(2):347-368.. The challenges involved in trying to redistribute doctors has been the subject of several government interventions; in spite of having attracted some health professionals to work in remote areas, these initiatives have not reached the numbers needed to meet the demands of the 5,570 Brazilian municipalities¹⁹19. Maciel Filho R. Estratégias para Distribuição e Fixação de Médicos em Sistemas Nacionais de Saúde 2007 [tese]. Rio de Janeiro: UERJ, 2007.

20. Pinto HÁ, Sales MJT, Oliveira FP, Brizolara R, Figueiredo AM, Santos JT. O Programa Mais Médicos e o fortalecimento da Atenção Básica.Divulg. saúde debate 2014; 51:105-120.^-2121. Weiller TH, Schimith MD. PROVAB: potencialidades e implicações para o Sistema Único de Saúde. J Nurs Health 2014; 3(2):145-146..

As a result of the prevailing shortage of doctors, in January 2013, the National Front of Brazilian Mayors (Frente Nacional dos Prefeitos do Brasil – FNP), launched a special campaign called Cadê o médico? (Where is the Doctor?). The Front also issued a petition demanding that the Federal Government contract foreign doctors to work in municipalities that had a shortage of physicians.

The universalization of the right to health, as enshrined in the Brazilian Constitution, represents a conquest achieved by the Brazilian people, which emerged from a movement known as the Health Care Reform Movement. One of the obstacles that have made it difficult to resolve the matter of the proper distribution of doctors and the consolidation of the Unified Health System – SUS with State politics was, and remains, the training of health professionals. Since 1976, there has been an on-going debate about how to train professionals in a way that is compatible with the health requirements of the general population²²22. Amancio A, Quadra AAF. Saúde, saber médico e recursos humanos.Saúde em Debate 1976; 1:48-49..

The new Curriculum Guidelines bring the training process of health professionals and the health needs of the population and the modus operandi of the Unified Health System (SUS) closer into line. However, the academic curricula of many Higher Education Institutions (HEIs) did not comply with these guidelines, thereby making it even more difficult for new professionals to gain access to the public health system²¹21. Weiller TH, Schimith MD. PROVAB: potencialidades e implicações para o Sistema Único de Saúde. J Nurs Health 2014; 3(2):145-146.. Other authors, such as Paim²³23. Paim J. Se depender dos governos o SUS não avança. Revista MUITO, Jornal A Tarde; 2013 Jul 28; p. 9-13., reinforce this point and state that the public health crisis in Brazil is also a crisis involving training, since courses in the health area, especially those related to medicine, are unable to train professionals who are capable of understanding the SUS in all its complexity;the SUS has becomediscredited – and I am not referring here to its many problems, which are indeed serious – due to a pre-judgment made by both the students and their teachers.

The More Doctors program was created under Law No. 12,871, dated October 22, 2013²⁴24. Brasil. Lei nº 12.871, de 22 de outubro de 2013. Institui o Programa Mais Médicos, altera as Leis no 8.745, de 9 de dezembro de 1993, e no 6.932, de 7 de julho de 1981 e dá outras providências. Diário Oficial da União 2013; 23 out. , and was based on three strategic fronts: i) more places and new Medical Courses based on the revised Curriculum Guidelines; ii) investing in the construction of Basic Health Units; iii) supplying Brazilian and foreign doctors. The latter is of a short-term nature to overcome the immediate problem of a shortage of doctors, until such a time as the structural measures begin to take effect. The supply of doctors has received more public visibility than the others, which has led to greater controversy. However, this will be discussed in greater detail in the following section; the other two initiatives will be approached jointly later on.

Providing doctors: evidence of the contribution that this Program has made to reduce the iniquity in the supply of doctors

The Program provided fourteen thousand four hundred and sixty-two Brazilian and foreign doctors to three thousand seven hundred and eighty-five municipalities (July, 2014). When analyzing how these doctors were distributed, it can been seen that the number of municipalities with a shortage of doctors in the PHC went from one thousand two hundred in March, 2013, to five hundred and fifty-eight in September 2014 (representing a reduction of 53.5%)²⁵25. Estação de Pesquisa de Sinais de Mercado (EPSM). Dados Estatísticos sobre o impacto do Programa Mais Médicos no cenário de escassez de médicos em atenção primária no Brasil. Belo Horizonte: EPSM/NESCON/FM/UFMG; 2015 [acessado 2015 set 29]. Disponível em: http://epsm.nescon.medicina.ufmg.br/epsm/Pesquisa_Andamento/Impacto_Programa_Mais_Medicos.pdf
http://epsm.nescon.medicina.ufmg.br/epsm... . This Program helped reduce iniquities, since the needs were met in 91.2% of the municipalities in the Northern region of Brazil which had a shortage of doctors, by supplying an average of 4.9 doctors per municipality (the highest ratio among the different regions). In short, this program met the requirements of the municipalities that had the most pressing needs, the worst ratios of doctors per inhabitants, were in situations of extreme poverty and high level of health care needs²⁵25. Estação de Pesquisa de Sinais de Mercado (EPSM). Dados Estatísticos sobre o impacto do Programa Mais Médicos no cenário de escassez de médicos em atenção primária no Brasil. Belo Horizonte: EPSM/NESCON/FM/UFMG; 2015 [acessado 2015 set 29]. Disponível em: http://epsm.nescon.medicina.ufmg.br/epsm/Pesquisa_Andamento/Impacto_Programa_Mais_Medicos.pdf
http://epsm.nescon.medicina.ufmg.br/epsm... .

Despite highlighting the shortcomings that need to be addressed, the report recently issued by the Federal Accounting Court (TCU) shows that after the More Doctors Program was implemented there was a 33% increase in the number of medical consultations provided and an increase of 32% in home visits, indicating an increase in the health care services offered²⁶26. Tribunal de Contas da União (TCU). Auditoria operacional: Programa Mais Médicos e Projeto Mais Médicos para o Brasil;avaliação da eficácia do programa. TC nº 005.391/2014-8..

The partial findings of the field study conducted by our team in the poorer municipalities located in the five main regions of Brazil showed that the Program had produced positive effects. The two hundred and sixty three SUS users involved in this study, showed a high level of satisfaction in relation to “waiting time to confirm a consultation” and “level of attention received during the consultation.” The majority stated that their privacy had been respected, that the doctors listened attentively to their complaints, provided the necessary information, gave clear explanations about the treatment involved and that they understood the advice given. In the case of interchange doctors, the Spanish language was not found to be a problem in communication. Similar findings were found in the above mentioned TCU report; among the two hundred and sixty-four patients interviewed, 57% described “having no difficulty at all” and 32% said they “only had slight difficulties,” in understanding what the foreign doctor was saying²⁶26. Tribunal de Contas da União (TCU). Auditoria operacional: Programa Mais Médicos e Projeto Mais Médicos para o Brasil;avaliação da eficácia do programa. TC nº 005.391/2014-8..

Interviews conducted with management and health professionals from the municipalities researched by our team indicated that the integration of medical professionals had broadened the capacity to diagnose local health problems in Brazil, and had also introduced greater agility and continuity in the treatment given to users. The Program added new health care experiences and practices, which contribute to the enhancement of PHC, in addition to ongoing support in the organization of services and teamwork.

Examples of the positive integration of Brazilian physicians who took part in the More Doctors Program were recently published²⁷27. Perez F. Sem vaga para os cubanos. Revista ISTO É; 2015 Mar 6; [acessado 2015 set 29]. Disponível em: http://www.istoe.com.br/reportagens/407830_SEM+VAGA+PARA+OS+CUBANOS
http://www.istoe.com.br/reportagens/4078... , showing how professionals committed to public health can make a positive contribution to a more qualified Primary Health Care. It is also an interesting statistic that 90% of the vacancies offered under the 2015 More Doctors Public Call were filled by Brazilian doctors²⁷27. Perez F. Sem vaga para os cubanos. Revista ISTO É; 2015 Mar 6; [acessado 2015 set 29]. Disponível em: http://www.istoe.com.br/reportagens/407830_SEM+VAGA+PARA+OS+CUBANOS
http://www.istoe.com.br/reportagens/4078... .

Investments in professional training and in the Basic Health Units

The Program is involved in professional training, providing new vacancies in Medical Courses under the aegis of the new, mandatory, Curriculum Guidelines, which changes the weightings of the subjects and envisages the early inclusion of medical students in the SUS. According to the Law, these courses are located according to the areas within the national territory where there is a shortage of doctors, in those municipalities where there are adequate SUS health care networks which can offer support for courses in Medicine, involving: primary health care; emergency care; psychosocial care; specialized outpatient and hospital care; and health surveillance²⁰20. Pinto HÁ, Sales MJT, Oliveira FP, Brizolara R, Figueiredo AM, Santos JT. O Programa Mais Médicos e o fortalecimento da Atenção Básica.Divulg. saúde debate 2014; 51:105-120.^,2424. Brasil. Lei nº 12.871, de 22 de outubro de 2013. Institui o Programa Mais Médicos, altera as Leis no 8.745, de 9 de dezembro de 1993, e no 6.932, de 7 de julho de 1981 e dá outras providências. Diário Oficial da União 2013; 23 out.^,2828. Brasil. Ministério da Saúde (MS). Mais Médicos. Abertas as inscrições de propostas para novos cursos de medicina. Blog [internet]. Brasília, 2014 dez 29. [acessado 2015 set 29]. Disponível em: http://www.blog.saude.gov.br/index.php/34941-mais-medicosabertas-as-inscricoes-de-propostas-para-novos-cursos-de-medicina
http://www.blog.saude.gov.br/index.php/3... . The Federal Government established as its goals the creation, by the year 2018, of eleven thousand five hundred new vacancies in undergraduate medicine and twelve thousand four hundred new medical residencies, which will focus on priority SUS areas²⁸28. Brasil. Ministério da Saúde (MS). Mais Médicos. Abertas as inscrições de propostas para novos cursos de medicina. Blog [internet]. Brasília, 2014 dez 29. [acessado 2015 set 29]. Disponível em: http://www.blog.saude.gov.br/index.php/34941-mais-medicosabertas-as-inscricoes-de-propostas-para-novos-cursos-de-medicina
http://www.blog.saude.gov.br/index.php/3... .

This Program has made important steps to implement the right to health by making it obligatory for municipalities to adhere to the Requalification of Primary Health Care Units (Requalifica UBS), which involves investments in the (re)construction of Basic Health Care Units. In order to obtain financial resources, the municipality has to register its proposal for construction, renovation or extension, which is analyzed by the Ministry of Health. For the years 2011, 2012 and 2013, six thousand three hundred and seventy-five, eight thousand three hundred and two, and eight thousand three hundred and seventy-three proposals, respectively, were completed. At present, there are twenty-three thousand and fifty Requalifica UBS projects planned, or being developed in Brazil. According to the Brazilian Ministry of Health, the estimated cost for the 2013-2014 period was R$3.3 billion, involving four thousand eight hundred and eleven municipalities²⁹29. Brasil. Ministério da Saúde (MS). Requalifica UBS[Internet]. 2014 [acessado 2015 set 29]. Disponível em: http://dab.saude.gov.br/portaldab/requalifica_ubs
http://dab.saude.gov.br/portaldab/requal... .

Final Considerations

The arguments set out in this paper show that the More Doctors Program is not a conceptual error. In addition to being based on the recognized needs of the population, it is in line with the constitutional principles of the SUS. Once the shortage of doctors was established, the Program took action to resolve this shortage in the short and medium-term, by associating the supply of doctors to the expansion and changes in professional training. The SUS still needs a great deal more to guarantee the universal right to health, but evidence shows that there is already a better distribution of doctors and a wider range of services being offered, especially in the more remote areas of the country. People living in cities, in the country and in the forests of Brazil want more doctors and better prospects of health and social justice.

Acknowledgments

To CNPQ by the sponsorship (Edital nº 41 CNPQ/MCT/Decit, 40351/ 2013).

References

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