The article by Gastão Wagner de Sousa Campos and Nilton Pereira Júnior entitled A Atenção Primária e o Programa Mais Médicos do Sistema Único de Saúde (“Primary Care and the ‘More Doctors Program’ of the Unified Health System”) reflects on the challenges presented by the development of primary healthcare (PHC) and healthcare networks in Brazil. The authors emphasize the importance of the introduction of the Programa Mais Médicos “More Doctors Program” (PMM) as a significant initiative on the part of the federal government, in conjunction with states and municipalities, to confront the challenges of introducing PHC in Brazil, and they highlight the progress, potential, and limitations in relation to this policy.

We would like to comment on the article and highlight some concerns about one of the aspects discussed therein, i.e. the adequacy of the training of health professionals, especially doctors, in relation to PHC.

The provision of professionals with appropriate professional qualifications, particularly doctors, for the Family Health Strategy (ESF) is one of the main challenges in terms of structuring PHC within Brazil. According to a recent study of medical demography conducted by Scheffer et al.¹1. Scheffer M, Biancarelli A, Cassenote A. Demografia Médica no Brasil 2015. São Paulo: DMPUSP, Cremesp, CFM; 2015., the number of doctors per capita in Brazil in 2015 was 2.11 doctors/1,000 inhabitants), which is low when compared to other countries, such as France (3.0 doctors/1000 inhabitants), the UK (2.7 doctors/1000 inhabitants) and Sweden (4.0 doctors/1000 inhabitants)²2. Organization for Economic Cooperation and Development (OECD). 2014. [acessado 2016 jan 2]. Disponível em: http://www.oecd-ilibrary.org/social-issues-migration-health/oecd-reviews-of-health-care-quality-united-kingdom-2016_9789264239487-en.
http://www.oecd-ilibrary.org/social-issu... , which are countries, like Brazil, that provide universal health systems. The distribution of doctors throughout Brazil is uneven in regions of the country, with more than half of doctors working in the southeast and a concentration of 55% working in the capitals of the federal units¹1. Scheffer M, Biancarelli A, Cassenote A. Demografia Médica no Brasil 2015. São Paulo: DMPUSP, Cremesp, CFM; 2015..

As the authors of this article indicate, the PMM has been presented as a policy that is designed to confront these issues. The second main issue that structures the PMM, i.e. vocational training, proposes medium and long-term solutions in relation to medical graduates and medical residencies, both in relation to training and the expansion of job vacancies. The target announced by the federal government regarding the PMM was to create 11,500 new graduate jobs and 12,400 residency positions by 2017³3. Brasil. Ministério da Saúde. Programa Mais Médicos, 2015. [acessado 2015 dez 1]. Disponível em: http://www.maismedicos.gov.br.
http://www.maismedicos.gov.br... , either by opening up new positions in existing undergraduate courses and residency programs, or through new courses and programs.

The issue of professional training is important in terms of strengthening PHC in Brazil because the emergency provision of foreign doctors is only a short-term measure; the consolidation of this initiative depends on training Brazilian doctors.

Regarding the issue of providing more graduates in medicine, in addition to expanding the number of trained professionals, the PMM is intended to seek alternatives in order to modify the profile of training and to encourage the provision of doctors throughout Brazil.

Article 4 of Law No. 12,871, which was passed in 2013, established the need for the effective implementation of the National Curriculum Guidelines (DCN) (2014) for the operation of medical courses in Brazil⁴4. Brasil. Lei n° 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.. One of the guidelines contained in the DCN was the requirement for 30% of the workload of those studying at medical schools to be performed in PHC and in emergency services provided by the SUS⁴4. Brasil. Lei n° 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.. Unlike the DCN published in 2001, the 2014 DCN included a deadline for implementation and requires all medical schools those guidelines by 2018⁵5. Brasil. Lei n° 11.741 de 16 de julho de 2008. Altera dispositivos da Lei n⍛ 9.394, de 20 de dezembro de 1996, que estabelece as diretrizes e bases da educação nacional, para redimensionar, institucionalizar e integrar as ações da educação profissional técnica de nível médio, da educação de jovens e adultos e da educação profissional e tecnológica. Diário Oficial da União 2008; 17 jul..

In the first two years of the PMM the program authorized the creation of 5,300 new medical graduate vacancies, 1,700 of which were in public universities (32%) and 3,600 of which were in private institutions (68%) throughout the whole of Brazil⁶6. Instituto Brasileiro de Geografia e Estatística (IBGE). Brasil, 2015. [acesso 2016 em jan 2]. Disponível em: http://www.ibge.gov.br/home/
http://www.ibge.gov.br/home/... . In 2015, the authorized rate of medical graduate vacancies per 10,000 inhabitants in the various Brazilian regions was as follows: mid-west (1.00 vacancies); northeast (0.98); north (1.05); southeast (1.20) and south (1.14); the national average was (0.81)³3. Brasil. Ministério da Saúde. Programa Mais Médicos, 2015. [acessado 2015 dez 1]. Disponível em: http://www.maismedicos.gov.br.
http://www.maismedicos.gov.br... .

Taking the state of Rio de Janeiro as an example, most of the authorized vacancies were in municipalities in the interior of the state, which is in line with one of the objectives of the PMM, i.e. the provision of medical professionals within the interior of Brazil. However, all these vacancies, and the majority of the vacancies nationwide, are in private institutions. Scheffer and Dal Poz⁷7. Scheffer MC, Dal Poz MR. The privatization of medical education in Brazil: trends and challenges. Human Resour Health 2015; 13: 96. analyzed a trend that has increased in recent decades towards the privatization of higher education in Brazil and they raised doubts about the possibility of guaranteeing quality assurance and democratic access through private medical courses. This trend also concerns us because it undermines the stability of this process and the necessary relationship that exists between these medical schools and public health services. The recent example of a medical school that went bankrupt in Rio de Janeiro exposed the dependence of that school on public investments for its operation and also the problems that were caused for the health service at which students at this school were enrolled⁸8. Rodrigues, A. Sala de aula vazia, bolso cheio na Gama Filho e UniverCidade. Revista Exame.com [internet] 02/08/2013 [acessado 2016 jun 2]. Disponível em: http://exame.abril.com.br/revista-exame/edicoes/1046/noticias/sala-de-aula-vazia-bolso-cheio.
http://exame.abril.com.br/revista-exame/... .

Similarly, the PMM has also had an impact on medical residency programs. The main way in which it has influenced the structuring of medical residency throughout Brazil has been by making it compulsory, from 2018, for all medical residency programs (except nine direct access specialties) to complete one year of residence in general family and community medicine”⁴4. Brasil. Lei n° 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.. Furthermore, the PMM proposes to expand medical residency programs. By December 2015, 4,742 vacancies in various specialties had been created throughout Brazil³3. Brasil. Ministério da Saúde. Programa Mais Médicos, 2015. [acessado 2015 dez 1]. Disponível em: http://www.maismedicos.gov.br.
http://www.maismedicos.gov.br... .

Regarding medical specializations, strengthening PHC depends on the training of qualified professionals to work within the Family Health Strategy (ESF) ¹1. Scheffer M, Biancarelli A, Cassenote A. Demografia Médica no Brasil 2015. São Paulo: DMPUSP, Cremesp, CFM; 2015.,⁹9. Póvoa L, Andrade MV. Distribuição geográfica dos médicos no Brasil: uma análise a partir de um modelo de escolha locacional. Cad Saude Publica 2006; 22(8):1555–1564.,¹⁰10. Nunes MPT, Borges LB, Guimarães DC, Cavalcanti LPG. Distribuição de vagas de residência médica e de médicos nas regiões do país. Cadernos da ABEM 2011; 37(4):28–34. There has been a progressive institutionalization and expansion of family and community medicine (FCM) as a medical specialization, as well as a significant increase in the number of FCM residency programs in Brazil.

However, it is noteworthy that in 2015 the occupancy rate of places on FCM residency programs in Brazil was 26.3%; of a total of 1,520 places only 400 were occupied. This is a cause for concern because we consider that specialization is crucial for the consolidation of PHC; the expansion of places that go unfilled will have a negative effect on medical provision for the ESF¹¹11. Trindade TG. Residência Médica em Medicina de Família e Comunidade. Apresentação em Power Point. SBMFC. Brasil, 2015. [acessado 2016 jan 2]. Disponível em: http://dkw4g894e1jim.cloudfront.net/images/PDF/10_Seminario_20ago2015_Residencia_em_MGFC_ThiagoTrindade_SBMFC.pdf
http://dkw4g894e1jim.cloudfront.net/imag... . As Campos and Campos and Pereira Júnior point out, aspects related to labor relationships and the careers of these doctors are pertinent to solving this problem.

To sum up, the PMM has undeniably resulted in advances; however, the trends identified in this article regarding the implementation of the program may obviate its beneficial effects regarding the structuring of medical training. It is essential to closely monitor this situation.

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