After three years of implementation of the Program comes the challenge of evaluating the impact of the “Mais Médicos” (More Doctors) Program (PMM) across the country in its component concerning the emergency provision of doctors. How can we evaluate a program of this magnitude, with so many realms of potential impact and peculiarities of implementation in such diverse contexts? This is the subject of the interview with PAHO/WHO Brazil Mais Médicos Program Technical Department Coordinator Renato Tasca.

Three years into the PMM, in your opinion, how can we assess the Program's impact?

This is not a simple question and its answer is complex, partly because we cannot evaluate in terms such as “success” or “failure”. These terms set definitive, radical and holistic judgments, and thus are much less adequate to define social outcomes and the public value of a program such as the PMM. It is a long-term, complex and comprehensive policy which is part of the historic process of building the Unified Health System (SUS) and cannot be synthesized with simplistic and/or reductionist adjectives of multiplicities, which define opposite ends such as success and failure.

What do you mean by that?

What I mean is that the PMM is not a single enterprise, a pilot project or an experiment to validate a method or theory. The program is based on robust scientific evidence of impact on the health conditions of the population it will benefit. And all the Program's actions are fully consistent with the Primary Health Care Policy of the SUS. The Program's positive outcomes, which are being progressively released, are not the result of unforeseen and unforeseeable circumstances, but rather the strengthening of the carefully planned primary health care network actions of the SUS enabled by the PMM. On second thought, the Program is a set of actions that take place in thousands of health facilities distributed across more than four thousand Brazilian municipalities. Each of these health installations has a doctor of the Program working in primary health care, and that is exclusively where a unique agreement is established between health staff and the population. When this covenant is fulfilled, a bond is created between them. The establishment of this agreement and the creation of this link is the true success, the greatest public value that the PMM adds to the lives of millions of Brazilians. Only this realm, which is difficult to calculate, can finally determine whether it is success or failure.

But starting from this situation, how can we evaluate the Program's impact?

We can indeed assess it, but we have to admit, a priori, the practical impossibility of reducing to a single realm and a single variable the judgment on something as complex as the PMM. It is therefore necessary to perform multiple analyzes to observe how, in different settings, the arrival of PMM has produced consequences that can produce a positive impact on the population. Advances made by the PMM must be analyzed according to the countless and multiple contexts in which the program is developed, extending to most of the country, encompassing different realities from all points of view.

The local realm, the uniqueness of each situation gives us the possibility of making a truer judgment, in which case, definitely, it can be defined as success or failure. However, there is no reason to expect that the PMM should not work. The program's mechanisms of action have been planned very carefully and in detail; yet it is impossible to predict all the variables, which are countless, everywhere, at all times. Hence the importance of monitoring and following-up the Program that is being implemented by different institutions.

What are the main variables that can influence the program's outcomes?

There are many variables. In addition to doctors' skills and their ability to integrate staff and the environment, other context factors are decisive so that, in a given place and for a given population, the arrival of PMM really makes a difference. Among them, we highlight the manager's ability to use the best possible way the energy provided by the Program to strengthen the municipal health system. For the manager, having strong primary health care teams means not only fulfilling a fundamental human right for many citizens, but is also a unique opportunity (in times of budget cuts) to introduce improvements and move forward in improving the care model and increasing the portfolio of services and the effectiveness.

So what kind of assessment do you propose to analyze the outcomes of the PMM?

Looking into the results of a comprehensive and complex public policy such as the PMM necessarily unravels new and fascinating evaluation horizons. Measuring changes in the health conditions of the population is per se insufficient to assess the public value caused by the PMM. Many other areas of outcomes have to be addressed and new elements have to be explored. We refer to the analysis of the PMM as an enabling factor for advancements in the development of health systems. This involves identifying factors that increase the ability to innovate health practices, qualifying and making Primary Health Care (PHC) more effective and efficient and organizing services in a more integrated and rational way to promote continuity of care, just to name a few. And I am just talking about the urgent provision line of action of the PMM.

In other words, a comprehensive review of PMM's implementation and impact in different contexts, and from the perspective of different stakeholders. How can we implement such an approach?

Implementing this vision is an arduous task, which entails major conceptual and methodological challenges, but the wealth of knowledge accumulated on the program makes me say that it is possible, especially if this task is faced with humility and a creative approach that is open to new ideas and knowledge.

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