Abstract

The Mais Médicos (More Doctors) Program (MMP), which was launched in 2013, sought to provide doctors to work in primary health care in priority areas within the Brazilian Unified Health System (SUS). This article analyzes the perception of MMP service users through the results of a qualitative study that consisted of interviews with service users of the Family Health Strategy (ESF) in which doctors from the MMP worked. The service users who were interviewed had a positive view of the MMP because it had expanded access to health care, although there still remained organizational and technical problems that limited the use of services. The performance of foreign doctors was well viewed, with an emphasis on a humanized relationship between doctor and service user, which was characterized by listening, attention and dialogue. In terms of communication with these professionals, some service users referred to language as being a barrier, which was ameliorated by the use of communication strategies within the ESF. The MMP offered a quick and satisfactory resolution to the historical problem of difficulty of access to doctors in Brazil. However, the effectiveness of the Brazilian health system requires that weaknesses are overcome, such as access to specialized services, organizational problems and the implementation of service production models that are centered on illness.

Key words
Primary health care; Health policy; Medical care; Human resources; Personnel management

Introduction

According to the World Health Organization (WHO), the shortage of health professionals is a global problem that undermines the establishment of national health systems; this problem is worse in regions with higher incidence of diseases¹1. Taylor AL, Hwenda L, Larsen BI, Daulaire N. Stemming the Brain Drain - A WHO Global Code of Practice on International Recruitment of Health Personnel. N Engl J Med 2011; 365(25):2348-2351. In order to meet the challenges arising from epidemiological and demographic transitions, and the redistribution of failure loads, there is need change these systems, as well as the profile of professionals and their training²2. Crisp N, Chen L. Global supply of health professionals. N Engl J Med 2013; 370(23):950-957..

In Brazil, the following federal government initiatives have been launched to attract and retain health professionals in remote regions of the country: the Program to Internalize Health and Sanitation Actions (PIASS - 1976); the Program to Internalize the Unified Health System (PISUS - 1993); the Program to Internalize Health Work (PITS - 2001); and the Program to Value Primary Care Professionals (PROVAB)³3. Oliveira FP, Vanni T, Pinto HA, Santos JTR, Figueiredo AM, Araújo SQ, Matos MFM, Cyrino EG. Mais Médicos: um programa brasileiro em uma perspectiva internacional. Interface (Botucatu) 2015; 19(54):623-634..

Despite these initiatives and the construction of the Unified Health System (SUS), which was accompanied by a significant expansion of health services⁴4. Organización Mundial de da Salud (OMS). La marcha del Brasil hacia la cobertura universal. Boletín de la Organización Mundial de la Salud. [acessado 2015 jun 10]. Disponível em: http://www.who.int/bulletin/volumes/88/9/10-020910/es/
http://www.who.int/bulletin/volumes/88/9... –⁶6. Lígia G, Maria HM. Atenção Primária à Saúde: seletiva ou coordenadorados cuidados? Rio de Janeiro: CEBES; 2012., other problems still compromise the guarantee of universal access to health care, including the unequal distribution of doctors. This results in a lack of health professionals in municipalities that are more distant from the large urban centers in Brazil⁷7. Conill EM. Ensaio histórico-conceitual sobre a Atenção Primária à Saúde: desafios para a organização de serviços básicos e da Estratégia Saúde da Família em centros urbanos no Brasil. Cad Saude Publica 2008; 24(Supl. 1):s7-s16.–⁹9. Duncan MS, Targa LV. Médicos para atenção primária em regiões rurais e remotas no Brasil: situação atual e perspectivas. Rev Bras Med Fam Comunidade 2014; 9(32):233-234.

Consequently, on July 8, 2013, through the enactment of Provisional Measure No. 621, the Brazilian government established the Projeto Mais Médicos (More Doctors Program), which was designed to reduce the shortage of doctors in Brazil, strengthen the SUS, reorganize national medical training and strengthen ongoing health education policy¹⁰10. Brasil. Medida Provisória n° 621, de 8 de julho de 2013. Institui o Programa Mais Médicos e dá outras providências. Diário Oficial da União 2013; 9 jul.. The Mais Médicos Program was changed by Law 12,871 on October 22, 2013, which reorganized the availability of medical courses and vacancies for medical residencies. It also created new parameters for Brazilian medical training and launched the Projeto Mais Médicos para o Brasil (More Doctors for Brazil Program), which was intended to allow the emergency provision of doctors to work in primary health care in priority areas of the SUS¹¹11. Brasil. Lei n° 12.871, de 22 de outubro de 2013. Institui o Programa Mais Médicos, altera as Leis n° 8.745, de 9 de dezembro de 1993, e n° 6.932, de 7 de julho de 1981, e dá outras providências. Diário Oficial da União 2013; 23 out..

The Mais Médicos Program recruited doctors to work in primary health care and compose teams working within the Family Health Strategy (ESF), which led to the hiring of medical staff from abroad after the Mais Médicos Program's first call for staff resulted in a low level of interest from Brazilian doctors¹²12. Brasil. Edital n° 39, de 8 de julho de 201. Adesão de médicos ao projeto mais médicos para o brasil. Diário Oficial da União 2013; 9 jul.. These staff are hired for a period of three years and they act under the supervision and mentoring of Brazilian universities to provide improvements in basic health care¹³13. Brasil. Portaria Interministerial n01369, de 13 de junho de 2011. Dispõe sobre a implementação do Projeto Mais Médicos para o Brasil. Diário Oficial da União 2011; 14 jun.. They have been deployed in areas that are considered to be a priority due to restricted access to health services, difficulty in providing doctors, and the increased vulnerability of the local population, according to criteria defined by Ordinance No. 1377, June 2011¹⁴14. Brasil. Portaria n01377, de 8 de julho de 2013. Dispõe sobre a implementação do Projeto Mais Médicos para o Brasil. Estabelece critérios para a definição das áreas e regiões prioritárias com carência e dificuldade de retenção de médico integrante de equipe de saúde da família. Diário Oficial da União 2013; 9 jul..

The premise is that the criteria for evaluating health reforms and their corresponding policies must come not only from managers and specialists but also from health workers, service users and other sectors of society¹⁵15. Bosi MLM, Mercado-Martinez FJ. Modelos avaliativos e reforma sanitária brasileira: enfoque qualitativo-participativo. Rev de Saude Publica 2010; 33(3):566-570.. Approaches that are guided by the perceptions of service users made possible the understanding of basic subjective aspects of healthcare, which, together with methodological rigor performed under new paradigmatic bases, especially comprehensive and dialectic, have led to their consolidation and growing scientific legitimacy¹⁶16. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 12ª ed. São Paulo: Hucitec; 2010.,¹⁷17. Bosi MLM, Mercado FJ, organizadores. Pesquisa qualitativa em serviços de saúde. 2ª ed. Petrópolis: Vozes; 2007.. Possible limits to these approaches have been highlighted, such as the unrepresentative nature of samples, the susceptibility of findings as to how data is collected, and the “otherness” of researchers in relation to the understanding of phenomena¹⁸18. Espiridião M, Trad LAB. Avaliação de satisfação de usuários. Cien Saude Colet 2005 10(Supl.):303-312., partly arise from a lack of understanding regarding other discursive fields, such as biomedicine, in relation to the ontological and epistemological nature of these approaches and, in part, they contain internal challenges regarding this investigative field¹⁹19. Bosi MLM. Pesquisa qualitativa em serviços de saúde: panorama e desafios. Cien Saude Colet 2012. 17(3):575-586.. Thus, this research set out to analyze the perceptions of service users regarding the Mais Médicos para o Brasil Program.

Methods

This qualitative study¹⁶16. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 12ª ed. São Paulo: Hucitec; 2010. was performed in the city of Mossoró, which is situated in the state of Rio Grande do Norte, Brazil. In April 2014, 14 exchange doctors from Cuba made up about 25% of the local ESF teams²⁰20. Prefeitura Municipal de Mossoró (PM Mossoró). Relação de médicos intercambistas. Mossoró: PM Mossoró; 2014.. The studied sites were the territories of the Basic Health Units (BHUs) that received these doctors.

The research subjects were residents of the territories served by the ESF teams that included the exchange doctors and who met the following criteria: they were aged over 18; they had resided for at least one year in the locality served by the ESF and that they had used the health services of the ESF where an exchange doctor was working. The exclusion criteria were the following: they did not have a minimum time of 30 minutes to conduct the interview; and they had direct kinship, an affinity relationship, or emotional involvement with an exchange doctor or any other professional working in the BHU where the research was conducted.

For the selection of the service users, firstly a territorial criterion was applied: an ESF was chosen with a foreign doctor in each of the five regions of the city (north, south, east, west and central), with priority being given to complete teams. Subsequently, the participants were selected from the territories where the health teams operated and an attempt was made to interview at least one per person from each micro-area of the area covered by a community health worker (ACS). An attempt was made to diversify the profile of the respondents according to age, gender and socioeconomic profile, so long as the inclusion criteria were respected.

The size of the sample was based on theoretical saturation²¹21. Turato ER, Fontanella BJB, Ricas J. Amostragem por saturação em pesquisas qualitativas em saúde: contribuições teóricas. Cad Saude Publica 2008; 24(1):17-27., which is used in qualitative studies, so there was a total of 25 respondents who were attended by six ESF teams covering all the regions of the city.

Individual semi-structured interviews²²22. Minayo MCS, Deslandes SF, Gomes R. Pesquisa social: teoria, método e criatividade. Rio de Janeiro: Vozes, 2007. were used to collect the data in an attempt to allow the interviewees to express themselves freely. The interviews were held in the homes of participants or in the health unit, when there was an appropriate place, according to the convenience of the respondent and ensuring the privacy and confidentiality of the information that was obtained.

The material was submitted to thematic analysis that involved the following methodological procedures: categorization (decomposing the analyzed material into parts and distributing them into categories); description (making a description of the results of categorization); inference (making inferences of the results); and interpretation (interpreting the results with the help of the adopted theoretical approach). In terms of practice, questions were formulated which aimed to find out the content of messages, without prior intervention and seeking to learn²²22. Minayo MCS, Deslandes SF, Gomes R. Pesquisa social: teoria, método e criatividade. Rio de Janeiro: Vozes, 2007.,²³23. Severino AJ. Metodologia do trabalho científico. 23ª ed. São Paulo: Cortez; 2007..

The analysis culminated in the establishment of the following three categories, from which the presentation of the results was structured: the views of service users about the Mais Médicos para o Brasil Program; access to primary health care: changes and continuities, and the perceptions of services users regarding the work of the foreign doctors.

This study followed the ethical principles set out in Resolution No. 466/2012 of the National Health Council; it was submitted to the Ethics Committee of the State University of Rio Grande do Norte (UERN) and approved.

Results and discussion

The views of service users regarding the Mais Médicos para o Brasil Program

The profiles of the service users who expressed their views about the Mais Médicos para o Brasil Program were based on the criteria of gender, education and age. In all, there were 25 research participants: 18 women (72%) and seven men (28%); 23 had middle or elementary school education (92%), one was illiterate (4%) and one had higher education (4%); four were aged over 60 (16%), 10 adults were aged between 30 and 60 (40%) and 11 young people were aged between 18 and 30 (44%).

The Mais Médicos para o Brasil Program was seen by these service users as an important governmental strategy to address the lack of doctors in BHUs and to improve access to doctors in primary health care, principally through the influx of foreign doctors. In less than a year the Mais Médicos para o Brasil Program recruited and allocated 14,462 doctors in 3,785 municipalities, of which there were 12,616 foreign doctors from 49 participating countries; of these 11,429 were Cuban doctors³3. Oliveira FP, Vanni T, Pinto HA, Santos JTR, Figueiredo AM, Araújo SQ, Matos MFM, Cyrino EG. Mais Médicos: um programa brasileiro em uma perspectiva internacional. Interface (Botucatu) 2015; 19(54):623-634..

The lack of doctors is getting a little better with these foreign doctors arriving; mainly in the health centers (Interviewee 3).

As well as increased ease of access to health services, the attention and respect given to service users by Cuban doctors were highlighted in this study as contributing to a positive evaluation of the Mais Médicos para o Brasil Program.

It's great because where they [Cuban doctors] are people say they are wonderful (Interviewee 5). Excellent, especially the Cuban [doctor], because he attends you well (Interviewee 2). I liked it very much. I think they [Cuban doctors] are better prepared because they have a conversation with you. They are very relaxed and treat people very well (Interviewee 18). It is a sign that the country is in need of doctors (Interviewee 19). I liked it because previously we came [to the health center] and had no doctor (Interviewee 20).

Some service users felt that the reason why foreign doctors were required was due to the fact that Brazilian doctors preferred to work in private practice rather than in the public SUS:

Brazilian doctors often don't want work for the SUS. Cuban doctors find it hard to work in their own country so they come here and they work for the SUS. Most Brazilian doctors complete their studies and when it comes to put their learning into practice they open a private clinic. But they [foreign doctors] don't; they accept to come here (Interviewee 10).

This is a complex issue. On the one hand, it involves the fact that the “unselfishness that characterized the beginning of the modern medical profession has long since been replaced by the professional ideology of valuing ultra-specialities, high personal incomes, and the transformation of health centers into microenterprises inserted within a competitive business market”²⁴24. Scheffer M. Programa Mais Médicos: em busca de respostas satisfatórias. Interface (Botucatu) 2015; 19(54):637-640..

On the other hand, the issue relates to the precariousness of work and the lack of investment in the work conducted by the SUS. The current situation regarding the labor market affects the production of health services, resulting in the degeneration of links, including the denial or omission of the constitutional rights of workers; the precariousness of work-related environments and conditions²⁵25. Santos-Filho SB. Um olhar sobre o trabalho em saúde nos marcos teórico-políticos da saúde do trabalhador e do humanizasus: o contexto do trabalho no cotidiano dos serviços de saúde. In: Santos-Filho SB, Barros MEB, organizadores. Trabalhador da saúde: Muito prazer! Protagonismo dos trabalhadores na gestão do trabalho em saúde. Ijuí: Unijuí; 2007. p. 272. (Coleção Saúde Coletiva).; the heteronomy of salaries; differentiated and unequal labor; the absence of planning regarding functions, careers and wages (PCCS); the absence of guidelines and technical/institutional principles in the hiring process due to clientelism; and the absence of a permanent education policy²⁶26. Medeiros SM, Rocha SMM. Considerações sobre a terceira revolução industrial e a força de trabalho em saúde em Natal. Cien Saude Colet 2004; 9(2):399-409..

Although they were less significant, there were also negative perceptions on the part of service users regarding the arrival of foreign doctors, which reflected concerns and uncertainties regarding the training of these professionals and the viability of communication with patients. There was an understanding that there should be greater investment in Brazilian doctors and that they should receive higher salaries

It's shameful on the part of the federal government, why? Because we have doctors all over Brazil! So they have to bring doctors here from abroad? Are they really trained doctors? (Interviewee 9). I think this implies that the service is not good, it is not efficient; firstly, because he [foreign doctor] does not understand the language, I did not understand what he said. I see this assistance from abroad as a problem and it is unnecessary (Interviewee 12). I think it would be much easier for them to pay more to our own doctors (Interviewee 13).

Allocating doctors to remote areas goes beyond the issue of salary: “the unattractive nature of regions with the worst social indicators and inadequate working conditions, excessive working hours and low pay hinders the hiring of doctors, and better salaries alone cannot compensate when doctors are subjected to professional isolation and a low quality of life for themselves and their families”²⁵25. Santos-Filho SB. Um olhar sobre o trabalho em saúde nos marcos teórico-políticos da saúde do trabalhador e do humanizasus: o contexto do trabalho no cotidiano dos serviços de saúde. In: Santos-Filho SB, Barros MEB, organizadores. Trabalhador da saúde: Muito prazer! Protagonismo dos trabalhadores na gestão do trabalho em saúde. Ijuí: Unijuí; 2007. p. 272. (Coleção Saúde Coletiva)..

It should be stressed that within the Mais Médicos para o Brasil Program “the following were eligible to participate: Brazilian doctors who graduated in Brazil or abroad, and foreign doctors, regardless of the place of graduation, so long as they came from countries where the number of doctors per capita was above 1.8 per thousand, which corresponded to the number of doctors per capita in Brazil before the implementation of the Mais Médicos para o Brasil Program”³3. Oliveira FP, Vanni T, Pinto HA, Santos JTR, Figueiredo AM, Araújo SQ, Matos MFM, Cyrino EG. Mais Médicos: um programa brasileiro em uma perspectiva internacional. Interface (Botucatu) 2015; 19(54):623-634.. The program eventually included 1,846 Brazilian doctors, which showed that there was relatively little interest in the program on the part of the latter”³3. Oliveira FP, Vanni T, Pinto HA, Santos JTR, Figueiredo AM, Araújo SQ, Matos MFM, Cyrino EG. Mais Médicos: um programa brasileiro em uma perspectiva internacional. Interface (Botucatu) 2015; 19(54):623-634..

Access to Primary Health Care: changes and continuity

In Brazil, access to health services within the SUS should be prioritized by primary care needs²⁷27. Brasil. Ministério da Saúde (MS). Decreto n° 7.508, de 28 de junho de 2011. Regulamenta a Lei no 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde - SUS, o planejamento da saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências. Diário Oficial da União 2011; 29 jun.. Ensuring access to health care is complex because it covers factors that are political (agreements between bodies, social control), economic and social (public investment, service user income), organizational (service flow, regulation, reference/counter-reference), technical (reception, quality of care), symbolic (culture, beliefs, values) and geographic²⁸28. Assis MMA, Jesus WLA. Acesso aos serviços de saúde: abordagens, conceitos, políticas e modelo de análise. Cien Saude Colet 2012; 17(11):2865-2875..

The service users attended by Mais Médicos para o Brasil Program doctors commented on access to services in terms of organizational and technical elements. Firstly, they pointed out that these doctors were more physically present in the UBS and, therefore, they differed from their Brazilian predecessors. Consequently, there was less uncertainty as to whether service users would be attended. In the Mais Médicos para o Brasil Program, doctors are expected to devote 32 hours per week to PHC work and eight hours to theoretical studies, which are subsequently evaluated³3. Oliveira FP, Vanni T, Pinto HA, Santos JTR, Figueiredo AM, Araújo SQ, Matos MFM, Cyrino EG. Mais Médicos: um programa brasileiro em uma perspectiva internacional. Interface (Botucatu) 2015; 19(54):623-634..

The doctor is very punctual (Interviewee 3). The Brazilian [doctors] came on the day that they wanted (Interviewee 5). The system for seeing the Cuban doctor is easier than trying to see the other doctor. Everybody says that the Cuban doctor always comes (Interviewee 12). It's good because it used to be so difficult to see a doctor here but now the situation has improved 100% (Interviewee 24).

Service users reported increased access to medical consultations and a reduction in the waiting time between scheduling and the consultation itself, which previously had sometimes taken months. However, the old system of making appointments (issuing tickets on a first-come first-served basis) still persisted, which resulted in queues at the UBS, even at dawn.

You have to come very early in the morning to get a ticket and sometimes you still aren't attended (Interviewee 1). It's much better now because you know that you will be seen. I take a ticket and I know that I will be seen tomorrow. The best situation would be to take a ticket and be seen on the same day (Interviewee 6). You go to the health center on a Friday and you can make an appointment for the following Monday or Tuesday (Interviewee 13).

The literature shows that this is still a widely used method in Brazil to organize access to medical consultations in terms of PHC. Studies of UBSs within the ESF in the Brazilian states of Ceará²⁹29. Serapioni M, Silva MGC. Avaliação da qualidade do Programa Saúde da Família em municípios do Ceará. Uma abordagem multidimensional. Cien Saude Colet 2011; 16(11):4315-4326., Pernambuco³⁰30. Azevedo ALM, Costa AM. A estreita porta de entrada do Sistema Único de Saúde (SUS):uma avaliação do acesso na Estratégia de Saúde da Família. Interface (Botucatu) 2010; 14(35):797-810,,³¹31. Mendes ACG, Miranda GMD, Figueiredo KEG, Duarte PO, Furtado BMASM. Acessibilidade aos serviços básicos de saúde: um caminho ainda a percorrer. Cien Saude Colet 2012; 17(11):2903-2912. and Bahia³²32. Cunha ABO, Vieira-da-Silva LM. Acessibilidade aos serviços de saúde em um município do Estado da Bahia, Brasil, em gestão plena do sistema. Cad Saude Publica 2010; 26(4):725-737.,³³33. Oliveira LS, Almeida LGN, Oliveira MAS, Gil GB, Alcione Brasileiro Oliveira C, Medina MG, Pereira RAG. Acessibilidade a atenção básica em um distrito sanitário de Salvador. Cien Saude Colet 2012; 17(11):3047-3056. have shown the reproduction of this model, which is associated with delays of up to 15 days from making an appointment to the consultation. A 2012 study based on the external evaluation of the data from the National Program to Improve Access to and the Quality of Primary Care (PMAQ) showed that more than 50% of service users in Brazil take a ticket in a UBS as a way to schedule their appointments and more than 30% of them have to queue at a UBS before it opens³⁴34. Fausto MCR, Giovanella L, Mendonça MHM, Seidl H, Gagno J. A posição da Estratégia Saúde da Família na rede de atenção à saúde na perspectiva das equipes e usuários participantes do PMAQ-AB. Saude Debate 2014; 38(esp):13-33..

This traditional and ineffective model forces service users to queue at the doors of health units, which organize fixed days and/or times for people to schedule medical consultations that are usually performed at the reception desk of the UBS by staff who are unqualified to exercise that function. When this model is performed correctly the scheduling of appointments is performed by a UBS health professional who screens service users before forwarding them to the appropriate doctor³⁵35. Luz J. Práticas de acolhimento e acesso aos serviços de atenção primária à saúde no brasil: uma análise qualitativa de 1990 a 2010 [monografia]. Florianópolis: Universidade Federal de Santa Catarina; 2012.. Regarding waiting time, although Mais Médicos para o Brasil Program service users mentioned a reduction in waiting time and increased access to services, it was still not possible to guarantee medical attention on a specific day, which was of major importance for service users.

In general, service users were positive about the performance of the new doctors in the UBS to which they were referred. However, they also pointed to barriers that compromised the resolution of their health problems such as access to medical specialties, medicines and examinations.

Is very difficult because, for example, you need a doctor, a specialist, you go to the health center and they give you a referral. You wait almost three months to get a consultation with a specialist, an ophthalmologist, a gynecologist (Interviewee 12). The lack of medicines is terrible (Interviewee 3). I needed some examinations, an MRI in August, and I finally had it yesterday after five months! (Interviewee 22).

Access to medical specialties is an aspect of great importance to providing an integral form of primary health care⁶6. Lígia G, Maria HM. Atenção Primária à Saúde: seletiva ou coordenadorados cuidados? Rio de Janeiro: CEBES; 2012.. The analysis of an external evaluation conducted by the PMAQ in 2012 revealed that 61.2% of service users in Brazil had to wait up to 30 days to access a specialized consultant after being attended in PHC³⁴34. Fausto MCR, Giovanella L, Mendonça MHM, Seidl H, Gagno J. A posição da Estratégia Saúde da Família na rede de atenção à saúde na perspectiva das equipes e usuários participantes do PMAQ-AB. Saude Debate 2014; 38(esp):13-33.. Although regulatory structures have been set up within municipal health departments in Brazil in order to integrate PHC services and specialized attention in recent years³⁶36. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. O sistema de saúde brasileiro: história, avanços e desafios. Lancet 2011; 11:31., other studies suggest that the waiting time is actually much higher than reported in the external evaluation performed of the PMAQ, which reinforces questions about the validity of this finding³⁴34. Fausto MCR, Giovanella L, Mendonça MHM, Seidl H, Gagno J. A posição da Estratégia Saúde da Família na rede de atenção à saúde na perspectiva das equipes e usuários participantes do PMAQ-AB. Saude Debate 2014; 38(esp):13-33.,³⁷37. Guerra AFM, Gonçalves DU, Côrtes MCJW, Alves CRL, Lima TMA. Otorrinolaringologia pediátrica no sistema público de saúde de Belo Horizonte. Rev Saude Publica 2007; 41(5):719-725.,³⁸38. Hoepfner C, Franco SC, Maciel RA, Hoepfner AMS. Programa de apoio matricial em cardiologia: qualificação e diálogo com profissionais da atenção primária. Saude Soc 2014; 23(3):1091-1101.. It is noteworthy that this waiting time also varies due to socioeconomic inequalities: it is generally higher for individuals with lower levels of economic power and education³⁹39. Nunes BP, Thumé E, Tomasi E, Duro SMS, Facchini LA. Desigualdades socioeconômicas no acesso e qualidade da atenção nos serviços de saúde. Rev Saude Publica 2014; 48(6):968-976..

Regarding access to medicines, studies have indicated that there is now a much higher supply within PHC: approximately 70% of prescribed medicines are dispensed in the UBSs³⁴34. Fausto MCR, Giovanella L, Mendonça MHM, Seidl H, Gagno J. A posição da Estratégia Saúde da Família na rede de atenção à saúde na perspectiva das equipes e usuários participantes do PMAQ-AB. Saude Debate 2014; 38(esp):13-33.,⁴⁰40. Ernani TSH, Silvia EA, Sergio MM. Percepção dos usuários sobre acesso aos medicamentos na Atenção Primária. Cad Saude Colet 2015; 23(3):280-288.. However, there is other evidence of the lack of medicines, which indicates the need for further research regarding pharmaceutical services within PHC⁴¹41. Vale e Silva J. Necessidade de Saúde: subsídios à prática do pensar fazer saúde [dissertação]. Fortaleza: Universidade Federal do Ceará; 2012..

From the perspective of service users, the implementation of the Mais Médicos para o Brasil Program has resulted in PHC that is more accessible in terms of medical consultations. However, it is important to note that barriers still remain that limit the ability to provide effective and timely health actions and services, which are associated with low levels of funding for health, technical and administrative limitations, poor organization and inefficiency in offering services, all of which are required to provide an integral service⁴²42. Santos LDE Andrade LOM. Acesso às ações e aos serviços de saúde: uma visão polissêmica. Cien Saude Colet 2012; 17 (11):2876-2880..

Opinions of service users about the work of foreign doctors

The work of the foreign doctors was perceived from the point of view of the doctor-service user relationship, the effectiveness of the medical consultation, and the communication with service users. The doctor-service user relationship emerged as a central issue. Respondents reported that they felt welcomed and encouraged to actively participate in their medical appointments. In general, they declared that they were satisfied and they praised the attitudes of the doctors for the way in which they were treated and the fact that they were given an opportunity to speak.

That's what I said, how he [the doctor] treats you, how he attends you. Do you understand? He doesn't have that attitude of being in a hurry. You don't have to talk if you don't want to, he gives you time (Interviewee 3). He is very attentive with us, he really looks at us. Some doctors just write notes when you are with them. ‘What's your problem?’ He's not like that. He looks; he listens, just as I am talking to you here. He looks in your eyes and asks you what your problem is (Interviewee 6).

The theme of the humanization of healthcare practices has guided the need for health care that is capable of combining technical and scientific knowledge with the recognition of the rights, culture and subjectivity of service users⁴²42. Santos LDE Andrade LOM. Acesso às ações e aos serviços de saúde: uma visão polissêmica. Cien Saude Colet 2012; 17 (11):2876-2880.. The aim is to overcome the over-valuation of the technical dimension in the management of the morpho-functional mechanisms related to disease at the expense of its human dimension, which sidelines sociocultural and emotional issues and excludes the reality of life and the knowledge and experiences of service users from medical therapy⁴³43. Deslandes S. Análise do discurso oficial sobre a humanização da assistência hospitalar. Cien Saude Colet 2004; 9(1):7-14.–⁴⁵45. Ayres JRCM. Uma Concepção Hermenêutica de Saúde. PHYSIS: Rev Saúde Coletiva 2007; 17(1):43-62..

This model of relationships, which is enshrined in health practices, was influenced by social medicalization, which hid the social character of illness, i.e. the medical-industrial complex that directed professional attention to machinery and equipment; the social determinations of life and health work; the generators of dehumanizing contexts; and the establishment and organization of health systems that submit professionals to increasingly routine and uncritical dynamics⁴⁶46. Gomes RM; Schraiber LB. A dialética humanização-alienação como recurso à compreensão crítica da desumanização das práticas de saúde: alguns elementos conceituais. Interface (Botucatu) 2011; 15(37):339-350.. Examples of this are the quantitative pressure for consultations and procedures, increases in the implementation of routines and protocols, and the precarious nature of professional conditions, stability and ties⁴¹41. Vale e Silva J. Necessidade de Saúde: subsídios à prática do pensar fazer saúde [dissertação]. Fortaleza: Universidade Federal do Ceará; 2012.,⁴⁷47. Gomes D, Ramos FRS. Subjetividade, ética e produtividade em saúde pós-reestruturação produtiva. Cien Saude Colet 2015; 8(20):2591-2600..

This dehumanization compromises the practical success of interventions, resulting in a failure to improve health conditions, which is promised by the potential of technical and scientific advances⁴⁵45. Ayres JRCM. Uma Concepção Hermenêutica de Saúde. PHYSIS: Rev Saúde Coletiva 2007; 17(1):43-62.. Moreover, there is a sense that medical work has been overshadowed by the idea of personal fulfilment to the detriment of its social dimension⁴⁷47. Gomes D, Ramos FRS. Subjetividade, ética e produtividade em saúde pós-reestruturação produtiva. Cien Saude Colet 2015; 8(20):2591-2600., which may be associated with the dissatisfaction and distrust of some service users regarding the behavior of health professionals, which in turn undermines the possibility of a good relationship between doctors and service users.

Another aspect highlighted in this study was the perceptions of service users in relation to the degree of resolution of their medical problems by the foreign doctors, which has also been commented on in a study of Brazilian doctors⁴⁸48. Turrini RNT, Lebrão ML, Cesar CLG. Resolutividade dos serviços de saúde por inquérito domiciliar: percepção do usuário. Cad Saude Publica 2008; 24(3):663-674..

All I ever need, she [the doctor] always solves. She gave me a prescription, I needed a few examinations, she sent me to another doctor, the appointment was made and I went to see the other doctor. What I mean is that every time that I have needed something she has solved it (Interviewee 17). What if I had had to live with that headache forever? That headache, what was it? My diabetes is not extreme. Why me? So I started taking the medicine, and today I feel better. I think that she was sent from God to help me with that headache (Interviewee 5).

The resolution of health issues is one of the main expectations of service users when they seek the help of health professionals, and the role of the doctor is particularly important because they are the professionals most sought by those requiring PHC⁴⁹49. Traverso-Yépez M, Morais NA. Reivindicando a subjetividade dos usuários da Rede Básica de Saúde: para uma humanização do atendimento. Cad Saude Publica 2004; 20(1):80-88..

In this study, the concept of resolution expressed by service users was synonymous with the control and treatment of illness, which confirmed the findings of other studies⁵⁰50. Silva RM, Viera CS, Toso BR, Neves ET, Rodrigues RM. Resolutividade na atenção à saúde da criança: percepção de pais e cuidadores. Acta Paul Enferm 2013; 26(4):382-388.. The service users generally referred to a high level of satisfaction with the services that they used, as was also found in other studies⁵¹51. Cotta RMM, Marques ES, Maia TM, Azeredo CM, Schott M, Franceschini SCC, Priore SE. A satisfação dos usuários do Programa de Saúde da Família: avaliando o cuidado em saúde. Scientia Medica 2005; 15(4):227-234.,⁵²52. Castro HCO, Machado LZ, Walter MIMT, Ranincheski SM, Schmidt BV, Marinho DNC, Campos TMA. A Satisfação dos Usuários com o Sistema Único de Saúde (SUS). Sociedade em Debate 2008; 14(2):113-134., which does not always reflect the quality of the services that are offered³⁰30. Azevedo ALM, Costa AM. A estreita porta de entrada do Sistema Único de Saúde (SUS):uma avaliação do acesso na Estratégia de Saúde da Família. Interface (Botucatu) 2010; 14(35):797-810,,⁵³53. Espiridião MA, Trad LAB. Avaliação de satisfação de usuários: considerações teórico-conceituais. Cad Saude Publica 2006; 22(6):1267-1276..

It should be noted that thinking about the issue of resolution in relation to integral PHC and the principles and guidelines of the SUS also implies, in addition to resolving the illnesses and injuries that are traditionally presented by the population, recognizing and addressing broader needs that are related to the determinants of the health-disease process and all the objective and subjective processes that compromise health and which do not find a satisfactory answer within the technical-scientific arsenal of biomedicine⁴¹41. Vale e Silva J. Necessidade de Saúde: subsídios à prática do pensar fazer saúde [dissertação]. Fortaleza: Universidade Federal do Ceará; 2012.,⁵⁴54. Campos CMS, Bataiero MO. Necessidades de saúde: uma análise da produção científica brasileira de 1990 a 2004. Interface (Botucatu) 2007; 11(23):605-618..

The service users interviewed in this study also spoke about the issue of communication with the foreign doctors. This question generated public debate in Brazil when the importation of foreign doctors was announced; there was some indignation on the part of Brazilian doctors and service users about possible problems related to language barriers, which were seen as a barrier to the quality of services that would be offered

A small number of service users reported that they had experienced no problems regarding the language of the foreign doctors. Most mentioned that they had had difficulty understanding the Cuban doctors; this was mentioned as a negative aspect, but that it had not made the consultation impossible.

There was a woman there with him [the foreign doctor], she was from the health center and she explains when we don't understand (Interviewee 1). When I don't understand I ask her [the foreign doctor] what she is saying. She makes gestures and then I understand what she is saying. Sometimes I don't understand and I call the girl to come and explain (Interviewee 15). I didn't have any problems regarding language, I understood everything (Interviewee 17). We were able to communicate. I liked it, I understood. He was patient, when I couldn't understand something he repeated it (Interviewee 20). The way he talks is a bit complicated for us, but when we ask him to explain he goes over it again and then we understand (Interviewee 5).

Conversation is a process of agreement that implies that both interlocutors are disposed to talk to each other, thereby promoting an exchange of views which culminates in a joint decision. Consequently, the dialogue between doctor and service user should aim to establish a link that promotes interaction between these individuals and that is capable of combining technical and practical success in the relationship that has been established⁴⁵45. Ayres JRCM. Uma Concepção Hermenêutica de Saúde. PHYSIS: Rev Saúde Coletiva 2007; 17(1):43-62.,⁵⁵55. Norman AH. O espaço de entrecruzamento das palavras: a relação médico-paciente. Rev Bras Med Fam Comunidade 2015; 10(35):1-3..

In the case of the foreign doctors, it is natural to assume that there would be some difficulty in communication during consultations. However, the problem lies not only in understanding the words themselves, but in understanding the message that is being conveyed. Caprara and Rodrigues⁴⁴44. Caprara A, Rodrigues J. A relação assimétrica médicopaciente: repensando o vínculo terapêutico. Cien Saude Colet 2004; 9 (1):139-146. studied Brazilian doctors working within the ESF and found that 39% of doctors did not explain medical problems in a clear and objective way and that in 58% of cases the professional did not check that the patient had understood the diagnosis.

Thus, the fact that doctors and service users share the same language does not guarantee that there is effective communication between them, due to the interference of factors such as the use of excessive technical language, different educational levels of service users, and the use of authoritative medical discourse.

It was observed that the fact that doctors were from countries where Portuguese is not the official language did not constitute an impediment to the interaction between individuals, compared to the use of communication strategies such as non-verbal language, speaking slowly and repeating what is said, and the help of other professionals to transmit messages.

Final considerations

The voices of the service users revealed that the Mais Médicos para o Brasil Program represents a breakthrough for the SUS because it has contributed to overcoming a historical and difficult problem, i.e. the expansion of access to health in the most deprived regions of Brazil. This trend aligns itself forcefully with international efforts to provide health staff.

However, the emergency nature of the implementation of the Mais Médicos para o Brasil Program merely shifts the challenges of providing doctors, and in the medium and long terms policies are required to simultaneously address problems related to the high turnover of doctors. Consolidating a public and universal health system that is guided by primary health care requires the effort and courage to face other structural problems, such as funding, as well as organizational, management and health care models.

References

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