Abstract

Shortages and imbalances in the distribution of the health workforce, are social and political problems that, along with the socio-economic inequality, reduce the access of the population to the health services. This study aims to understand the challenges of SUS policy-makers and managers to ensure the availability and geographical accessibility to health service providers. The analysis was guided by a framework of the health labour market and health policy interventions. Two main problems have been identified: shortage of doctors and maldistribution of professionals between levels of health care and between geographical areas. This review focused on eight interventions in the last 30 years, whose mainly aim was to correct the maldistribution of physicians in the SUS such as Rondon Project, Interiorization of Health Work Program, Medical Specialists Training Program, PHC Program and More Doctors Program. The discussion focuses on the factors that influence the outcome of these interventions.

Human resources in for health; Health employment labour market; Public health policies in health; Physicians distribution of doctors; Access to health care

Introduction

The Brazilian Health System comprises a complex network of public and private services, complementing each other in some services, and competing principally in the area of qualified human resources in health. In 1998 the Brazilian Unified Health System (Sistema Único de Saúde – ‘Unified Health System’, or SUS) was put in place, with the commitment to provide universal, integrated coverage of healthcare. This commitment becomes an even greater challenge in view of the fact that Brazil, although it is the largest economy in Latin America, has a high degree of economic and social inequality¹1. Pan American Health Organization. Health in the Americas: Brazil. Heal Am 2012:129-145.,²2. Girardi SN, Carvalho CL, Araújo JF, Farah JM, Wan der Maas L, Campos LAB. Índice de escassez de médicos no Brasil: estudo exploratório no âmbito da Atenção Primária. In: Pierantoni CR, Dal Poz MR, França T, organizadores. O trabalho em Saúde: abordagens quantitativas e qualitativas. Rio de Janeiro: Cepesc/IMS/UERJ, ObservaRH; 2011. p. 171-186.. The health systems are in need, among other changes, of an adequate workforce – human resources for healthcare are seen as one of the pillars for achieving the objective of reducing access barriers to the Healthcare Network (RAS) for the population³3. Craveiro IMR, Hortale VA, Oliveira APC, Dussault G. Desigualdades sociais, políticas de saúde e formação de médicos, enfermeiros e dentistas no Brasil e em Portugal. Cien Saude Colet 2015; 20(10):2985-2998..

Availability of motivated, involved and supported health professionals with relevant competencies, in a sufficient number, allocated in the places where they are necessary, is essential for the management and provision of services of health in all countries⁴4. World Health Organization (WHO). World Health Report: 2006: Working Together for Health. Geneva: WHO; 2006. Vol 19.

5. Dussault G, Dubois C-A. Human resources for health policies: a critical component in health policies. Hum Resour Health 2003; 1(1):1.-⁶6. World Health Organization (WHO). The World Health Report: 2000: Health Systems: Improving Performance. Geneva: WHO; 2000. Vol 78., and performance is, in turn, determined by the policies and practices that define the number of people to be allocated, their qualifications and the working conditions⁵5. Dussault G, Dubois C-A. Human resources for health policies: a critical component in health policies. Hum Resour Health 2003; 1(1):1..

The imbalance in the workforce, with the inadequate geographical distribution and in particular the lack of qualified healthcare human resources in the rural or needy regions is a social and political problem that affects almost all countries²2. Girardi SN, Carvalho CL, Araújo JF, Farah JM, Wan der Maas L, Campos LAB. Índice de escassez de médicos no Brasil: estudo exploratório no âmbito da Atenção Primária. In: Pierantoni CR, Dal Poz MR, França T, organizadores. O trabalho em Saúde: abordagens quantitativas e qualitativas. Rio de Janeiro: Cepesc/IMS/UERJ, ObservaRH; 2011. p. 171-186.,⁴4. World Health Organization (WHO). World Health Report: 2006: Working Together for Health. Geneva: WHO; 2006. Vol 19.,⁵5. Dussault G, Dubois C-A. Human resources for health policies: a critical component in health policies. Hum Resour Health 2003; 1(1):1.,⁷7. 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(c):623-634.

8. Kroezen M, Dussault G, Craveiro I, Dieleman M, Jansen C, Buchan J, Barriball L, Rafferty AM, Bremner J, Sermeus W. Recruitment and retention of health professionals across Europe: a literature review and multiple case study research. Health Policy 2015; 119(12):1517-1528.

9. Scheffer MC, Dal Poz MR. The privatization of medical education in Brazil: trends and challenges. Hum Resour Health 2015; 13(1):96.

10. Campos FE, Machado MH, Girardi SN. A fixação de profissionais de saúde em regiões de necessidades. Divulg em Saúde para Debate 2009; 44(maio):13-24.-¹¹11. Dussault G, Franceschini MC. Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Hum Resour Health 2006; 4(1):12.. Associated with socio-economic inequality, this imbalance reduces the population’s access to health services.

The objective of the study is to understand the challenges facing policy makers and managers of the SUS in ensuring geographical availability and accessibility to doctors in the Brazilian public service. More specifically: to identify the challenges of geographical availability and accessibility, analyzing the causes, and mapping the timetable of the policy strategies that have been implemented, at a national level, that have aimed to guarantee the population’s access to health services from the SUS.

Methodology

This article is part of a multiple case study, focusing on the process of decision on policies directed to the problem of geographical distribution of healthcare human resources, in Brazil and in Portugal, and whether or not it is informed by scientific evidence. The focus of this phase of the study is to analyze the policy context affecting healthcare human resources in Brazilian. Use was made of information from research documents, technical and political documents, and secondary quantitative data. To identify these documents and data three strategies were used, described in Chart 1.

To orient the analysis, an adaptation of the conceptual table of the employment market and health policy¹²12. Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bull World Health Organ 2013; 91(11):892-894. was used, illustrated in Figure 1. The table can be used by policy makers and decision makers to help understand the flows of the employment market, and to orient policy interventions¹³13. Vujicic M, Zurn P. The dynamics of the health labour market. Int J Health Plann Manage 2006; 21(2):101-115., for work toward formation of a stock of that is desirable in terms of size, composition, distribution, quality and effectiveness for meeting the needs of healthcare and services.

Based on the conceptual table, the data were submitted to a subject analysis, extracting the information from the documents in accordance with predetermined categories and subcategories, including some categories based on reading of the documents, as shown in Chart 2.

An attempt was made to assess the continuity between the policies of governments for the problems of healthcare human resources, and especially on geographical availability and accessibility to doctors.

Results

Based on the research on the site and with the information from the key sources of advice consulted, it was possible to identify 22 policy and technical documents. In the database search a total of 2,191 documents were identified. After application of the criteria of eligibility, 20 were selected for analysis: see Figure 2. The complete list of the 44 documents used in this study is available on request.

I - Challenges for ensuring availability and geographical access to doctors, and the related determinant factors

The quantity, distribution and quality of the health professionals that are accessible to populations are fundamental conditioning factors for achieving gains in health¹⁴14. Sousa A, Dal Poz MR, Boschi-Pinto C. Reducing inequities in neonatal mortality through adequate supply of health workers: evidence from newborn health in Brazil. PLoS One 2013; 8(9):e74772.. In spite of the increasing evidence that the workforce in health is fundamental for improving the levels of coverage of health services for the population, several countries still have serious problems with scarcity¹⁴14. Sousa A, Dal Poz MR, Boschi-Pinto C. Reducing inequities in neonatal mortality through adequate supply of health workers: evidence from newborn health in Brazil. PLoS One 2013; 8(9):e74772.

15. Campos FE. Funding, flexible management needed for Brazil’s health worker gaps. Interview by Claudia Jurberg. Bull World Health Organ 2013; 91(11):806-807.-¹⁶16. Campbell J, Buchan J, Cometto G, David B, Dussault G, Fogstad H, Fronteira I, Lozano R, Nyonator F, Pablos-Méndez A, Quain EE, Starrs A, Tangcharoensathien V. Human resources for health and universal health coverage: fostering equity and effective coverage. Bull World Heal Organ 2013; 91(11):853-863., and inequalities in the distribution of these professionals⁴4. World Health Organization (WHO). World Health Report: 2006: Working Together for Health. Geneva: WHO; 2006. Vol 19.,⁵5. Dussault G, Dubois C-A. Human resources for health policies: a critical component in health policies. Hum Resour Health 2003; 1(1):1.,¹⁷17. World Health Organization (WHO). Increasing Access to Health Workers in Remote and Rural Areas through Improved Retention. Geneva: WHO; 2010.,¹⁸18. Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M, Cueto M, Dare L, Dussault G, Elzinga G, Fee E, Habte D, Hanvoravongchai P, Jacobs M, Kurowski C, Michael S, Pablos-Mendez A, Sewankambo N, Solimano G, Stilwell B, de Waal A, Wibulpolprasert S. Human resources for health: overcoming the crisis. Lancet 2004; 364(9449):1984-1990.. This problem is highlighted in countries that offer universal coverage, with a vast geographical area and an unequally distributed population. In this document we will focus on two principal problems identified in the studies:(a) scarcity of doctors, and (b) inadequate distribution. The latter relates to geographical zones and distribution between the levels of healthcare.

(a) Scarcity of doctors

Brazil’s density of doctors per thousand population has grown over the last 20 years. In 1990 the country had 1.12 doctors per thousand population, and this increased to 1.86 in 2010¹⁹19. Brasil. Ministério da Saúde (MS). Rede Interagencial de Informação para a Saúde (RIPSA). Indicadores e Dados Básicos - Brasil - 2012 IDB-2012. Brasília: MS; 2013.. Other sources with more up-to-date data showed that in 2013 this ratio was 1.89 per thousand population²⁰20. World Health Organization (WHO). Global Health Observatory Data Repository: Browse data tables by indicator. Geneva: WHO; 2015., and in 2015 it was 1.95²¹21. Scheffer M, Cassenote A, Biancarelli A. Demografia Médica No Brasil. São Paulo: FMUSP; 2015..

Decision on exactly what is the ideal ratio of doctors to population in a country is a polemical and complex subject. Various factors need to be taken into account, in particular: characteristics of the professional (social-demographic – age, gender); work processes (productivity, workload, non-clinical work and variations in level of activity), characteristics of the health system in place in the country (for example, coverage and type of services offered)²²22. Pong RW, Pitblado JR. Geographic distribution of Physicians in Canada: beyond how many and where. Ottawa: Can Inst Heal Inf; 2005., and the population’s conditions (socio-economic and epidemiological).

Making this ratio operational is in some cases limited by difficulties²²22. Pong RW, Pitblado JR. Geographic distribution of Physicians in Canada: beyond how many and where. Ottawa: Can Inst Heal Inf; 2005., possibly caused by lack of information. Additionally, in Brazil there is no set planning of the future needs for healthcare human resources. This situation was reflected in the documents analyzed, which showed scarcity of doctors. These documents use data comparing ratio of doctors per thousand population between Brazil and other countries, to arrive at a desirable ratio and create targets for improvement. Sometimes, a fixed ideal minimum ratio is attributed, without considering the contextual factors referred to above.

The OECD data for numbers of doctors per thousand population of various countries should be used with caution. On this basis, Brazil is sixth lowest of 39 countries that presented available data for the year 2010 (also the last year relating to Brazil)²³23. OECD. OECD data: health resources: doctors. 2016. [acessado 2016 fev 15]. Disponível em: https://data.oecd.org/healthres/doctors.htm
https://data.oecd.org/healthres/doctors.... .

The publications reported scarcity, with inappropriate geographical distribution and shortage of professionals and specialists in Primary Healthcare⁹9. Scheffer MC, Dal Poz MR. The privatization of medical education in Brazil: trends and challenges. Hum Resour Health 2015; 13(1):96.,¹⁰10. Campos FE, Machado MH, Girardi SN. A fixação de profissionais de saúde em regiões de necessidades. Divulg em Saúde para Debate 2009; 44(maio):13-24.,¹⁶16. Campbell J, Buchan J, Cometto G, David B, Dussault G, Fogstad H, Fronteira I, Lozano R, Nyonator F, Pablos-Méndez A, Quain EE, Starrs A, Tangcharoensathien V. Human resources for health and universal health coverage: fostering equity and effective coverage. Bull World Heal Organ 2013; 91(11):853-863., and attributed the causes of scarcity principally to:

• Growing demand for professionals, due especially to the increase in public and private medical service establishments¹⁰10. Campos FE, Machado MH, Girardi SN. A fixação de profissionais de saúde em regiões de necessidades. Divulg em Saúde para Debate 2009; 44(maio):13-24.,²¹21. Scheffer M, Cassenote A, Biancarelli A. Demografia Médica No Brasil. São Paulo: FMUSP; 2015.. With the reform of primary healthcare in the Americas and implementation of the Family Health Strategy²⁴24. Organização Pan-Americana de Saúde (OPAS). Renovação da Atenção Primária em Saúde nas Américas. Brasília: OPAS; 2007.,²⁵25. Brasil. Ministério da Saúde (MS). Política Nacional de Atenção Básica. Vol I; 2012. [acessado 2016 fev 10]. Disponível em: http://189.28.128.100/dab/docs/publicacoes/geral/pnab.pdf
  http://189.28.128.100/dab/docs/publicaco... , which created multi-professional health teams and broadened service to the Brazilian population, there was a consequent increase in the need for doctors for primary healthcare. The number of health establishments at the end of the 1970s was 18,489, and by 2005 this number had grown to 77,004, an increase of approximately 76%¹⁰10. Campos FE, Machado MH, Girardi SN. A fixação de profissionais de saúde em regiões de necessidades. Divulg em Saúde para Debate 2009; 44(maio):13-24.;

• Low number of people coming out of medical training, compared to the demand and the growing needs referred to above. It is shown by the significant growth in the number of medical courses in the country – approximately 63% from 94 to 251 over the period 2000 to 2014²⁶26. ObservaRH IMS/UERJ. Observatório de Recursos Humanos em Saúde/Estação de Trabalho do Instituto de Medicina Social da Universidade do Estado do Rio de Janeiro. Sistema de Indicadores das Graduações em Saúde - SIGRAS. [acessado 2016 fev 10]. Disponível em: http://www.obsnetims.org.br/sigras/home.php
  http://www.obsnetims.org.br/sigras/home.... . More recent data show a total of 257 courses in 2015 a significant increase of 69 courses in approximately 6 years²¹21. Scheffer M, Cassenote A, Biancarelli A. Demografia Médica No Brasil. São Paulo: FMUSP; 2015.. This increase was accompanied by an inversion in the predominance of courses in the public and private higher education institutions. In 2000 there were 48 higher education courses in public institutions and 82 in private institutions, and by 2010 these had risen to 78 and 103 respectively²⁶26. ObservaRH IMS/UERJ. Observatório de Recursos Humanos em Saúde/Estação de Trabalho do Instituto de Medicina Social da Universidade do Estado do Rio de Janeiro. Sistema de Indicadores das Graduações em Saúde - SIGRAS. [acessado 2016 fev 10]. Disponível em: http://www.obsnetims.org.br/sigras/home.php
  http://www.obsnetims.org.br/sigras/home.... , public higher education institutions being concentrated in the state capital cities⁹9. Scheffer MC, Dal Poz MR. The privatization of medical education in Brazil: trends and challenges. Hum Resour Health 2015; 13(1):96.. This predominance has been becoming more accentuated, and data show that the numbers of new places available in the last two years in private and public higher education institutions were respectively 3,600 and 1,700²⁷27. Brasil. Programa Mais Médicos Governo Federal: estudantes de graduação em medicina. 2016. [acessado 2016 fev 1]. Disponível em: http://maismedicos.gov.br/cursos-de-graduacao
  http://maismedicos.gov.br/cursos-de-grad... , with the places in private institutions being concentrated in the country’s Southeastern Region, and those in public institutions in the Northern Region⁹9. Scheffer MC, Dal Poz MR. The privatization of medical education in Brazil: trends and challenges. Hum Resour Health 2015; 13(1):96..

b. Inappropriate distribution of doctors between the levels of healthcare and geographical zones

Considering the network model on the basis of which the SUS is organized²⁸28. Brasil. Ministério da Saúde (MS). Portal da saúde: as redes de atenção a saúde. [acessado 2016 fev 15]. Disponível em: http://dab.saude.gov.br/portaldab/smp_ras.php
http://dab.saude.gov.br/portaldab/smp_ra... , the problem of inadequate distribution cannot be analyzed only with the focus on primary healthcare, but also on the other levels of care. The specialists who operate exclusively in the private sector and the public sector total, respectively, 68.2% and 52%, while 74.3% of the total operate in both. It was found that in the private sector 40.1% are in consultation rooms, 38.1% in hospitals and 31.1% in outpatient facilities. In the public sector, 51.5% work in hospitals, 23.5% in primary healthcare and 4.8% in secondary care²¹21. Scheffer M, Cassenote A, Biancarelli A. Demografia Médica No Brasil. São Paulo: FMUSP; 2015..The number of pediatric surgeons showed imbalances between the regions of the country, the Southeast being the largest source of training and qualification of in this specialty²⁹29. Jesus LE, Aguiar AS, Campos MSM, Baratella JRS, Ketzer JC, Mastroti RA, Amarante ACM. Formação e demanda do cirurgião pediátrico no Brasil. Rev Col Bras Cir 2009; 36(4):356-361.. Among dermatologists, only 9.1% of the municipalities had a specialist in this area³⁰30. Schmitt JV, Miot HA. Distribution of Brazilian dermatologists according to geographic location, population and HDI of municipalities: An ecological study. An Bras Dermatol 2014; 89(6):1013-1015.. In ophthalmology, the imbalance in geographical distribution results in scarcity in certain zones, however this analysis was not attributed to lack of specialists in the country. Those studies that dealt with inadequate distribution in other specialties were found.

The problem of inadequate geographic distribution of healthcare professionals in Brazil has been indicated as a challenge, and various policy strategies have been implemented to correct it⁷7. 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(c):623-634.,¹⁰10. Campos FE, Machado MH, Girardi SN. A fixação de profissionais de saúde em regiões de necessidades. Divulg em Saúde para Debate 2009; 44(maio):13-24.,¹⁴14. Sousa A, Dal Poz MR, Boschi-Pinto C. Reducing inequities in neonatal mortality through adequate supply of health workers: evidence from newborn health in Brazil. PLoS One 2013; 8(9):e74772.,²¹21. Scheffer M, Cassenote A, Biancarelli A. Demografia Médica No Brasil. São Paulo: FMUSP; 2015.,³¹31. Buchan J, Fronteira I, Dussault G. Continuity and change in human resources policies for health: lessons from Brazil. Hum Resour Health 2011; 9(1):17.

32. Dal Poz MR. The health workforce crisis. Cad Saude Publica 2013; 3(10):1924-1926.

33. Póvoa L, Andrade MV. Geographic distribution of physicians in Brazil: an analysis based on a locational choice model. Cad Saude Publica 2006; 22(8):1555-1564.

34. Carvalho MS, Sousa MF. Como o Brasil tem enfrentado o tema provimento de médicos? Interface Commun Heal Educ 2013; 17(47):913-926.

35. Carvalho MS. Programa de Valorização dos Profissionais da Atenção Básica: um olhar implicado sobre sua implantação. 2013:167. [acessado 2016 feb 15]. Disponível em: http://repositorio.unb.br/handle/10482/13660
http://repositorio.unb.br/handle/10482/1...

36. Maciel Filho R. Estratégias para a distribuição e fixação e médicos em sistemas nacionais de saúde: o caso brasileiro [tese]. Rio de Janeiro: UERJ; 2007.-³⁷37. Brasil. Ministério da Saúde (MS). Programa Mais Médicos – Dois Anos: Mais Saúde para os Brasileiros. Brasília: MS; 2015.. This inappropriate distribution is accentuated in qualified health professionals including nurses, doctors¹⁴14. Sousa A, Dal Poz MR, Boschi-Pinto C. Reducing inequities in neonatal mortality through adequate supply of health workers: evidence from newborn health in Brazil. PLoS One 2013; 8(9):e74772. and dentists³⁸38. Pucca GA, Gabriel M, Araujo ME, Almeida FCS. Ten Years of a National Oral Health Policy in Brazil: Innovation, Boldness, and Numerous Challenges. J Dent Res 2015; 94(10):1333-1337., and this situation is directly reflected in the population’s health conditions¹⁴14. Sousa A, Dal Poz MR, Boschi-Pinto C. Reducing inequities in neonatal mortality through adequate supply of health workers: evidence from newborn health in Brazil. PLoS One 2013; 8(9):e74772.,¹⁶16. Campbell J, Buchan J, Cometto G, David B, Dussault G, Fogstad H, Fronteira I, Lozano R, Nyonator F, Pablos-Méndez A, Quain EE, Starrs A, Tangcharoensathien V. Human resources for health and universal health coverage: fostering equity and effective coverage. Bull World Heal Organ 2013; 91(11):853-863..

This adverse distribution is seen in various geographic levels (between regions, between rural and urban, between the interior of a state and its capital city, and between the municipalities themselves). There is an asymmetry in the distribution of doctors between Brazil’s five Regions. In the Southeastern Region there are 2.51 doctors per thousand population, that is to say a concentration 2.5 times greater than in the Northeast (0.9) in the year 2010. The ratio in the South (2.06) and the Center-West (1.76) is almost twice the ratio for the Northeast (1.09)¹⁹19. Brasil. Ministério da Saúde (MS). Rede Interagencial de Informação para a Saúde (RIPSA). Indicadores e Dados Básicos - Brasil - 2012 IDB-2012. Brasília: MS; 2013.. So we see a greater intensity of the problem in the North and Northeast, which are below the national average¹⁰10. Campos FE, Machado MH, Girardi SN. A fixação de profissionais de saúde em regiões de necessidades. Divulg em Saúde para Debate 2009; 44(maio):13-24.,²¹21. Scheffer M, Cassenote A, Biancarelli A. Demografia Médica No Brasil. São Paulo: FMUSP; 2015.,³³33. Póvoa L, Andrade MV. Geographic distribution of physicians in Brazil: an analysis based on a locational choice model. Cad Saude Publica 2006; 22(8):1555-1564.

34. Carvalho MS, Sousa MF. Como o Brasil tem enfrentado o tema provimento de médicos? Interface Commun Heal Educ 2013; 17(47):913-926.

35. Carvalho MS. Programa de Valorização dos Profissionais da Atenção Básica: um olhar implicado sobre sua implantação. 2013:167. [acessado 2016 feb 15]. Disponível em: http://repositorio.unb.br/handle/10482/13660
http://repositorio.unb.br/handle/10482/1...

36. Maciel Filho R. Estratégias para a distribuição e fixação e médicos em sistemas nacionais de saúde: o caso brasileiro [tese]. Rio de Janeiro: UERJ; 2007.-³⁷37. Brasil. Ministério da Saúde (MS). Programa Mais Médicos – Dois Anos: Mais Saúde para os Brasileiros. Brasília: MS; 2015.. The inequality between Brazil’s States is even greater, while the Federal District, Rio de Janeiro and São Paulo have respectively 3.61, 3.52 and 2.5 doctors per thousand population, in these states of Pará, Amapá and Maranhão this ratio falls to 0.77, 0.75 and 0.53 respectively¹⁹19. Brasil. Ministério da Saúde (MS). Rede Interagencial de Informação para a Saúde (RIPSA). Indicadores e Dados Básicos - Brasil - 2012 IDB-2012. Brasília: MS; 2013..

The inadequate distribution of doctors is more accentuated between municipalities. Those with the lowest population have the lowest number of doctors per inhabitant²¹21. Scheffer M, Cassenote A, Biancarelli A. Demografia Médica No Brasil. São Paulo: FMUSP; 2015.. In 2009 approximately 42% of the population lived in municipalities with a ratio of less than 1 doctor per 4,000 population, and in 7% of municipalities there were no records of doctors at all¹⁰10. Campos FE, Machado MH, Girardi SN. A fixação de profissionais de saúde em regiões de necessidades. Divulg em Saúde para Debate 2009; 44(maio):13-24.. Municipalities with population of up to 50,000 were 88.5% of the total (4,932 municipalities in 2014) and had between 0.23 and 0.64 doctors per thousand population. At the other extreme, municipalities with more than 500,000 population (a total of 39 in 2014) have 29% of the country’s population and approximately 61% of the doctors²¹21. Scheffer M, Cassenote A, Biancarelli A. Demografia Médica No Brasil. São Paulo: FMUSP; 2015..

This imbalance is influenced by various factors, which can be divided into: individual; organizational; and related to the systems (health, education, institutional) and characteristics of the municipalities, including the economic, socio-cultural, historic and political environment¹¹11. Dussault G, Franceschini MC. Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Hum Resour Health 2006; 4(1):12.. In the documents selected, the principal causes of inappropriate geographical distribution in Brazil were: the characteristics of the municipalities, including their GDP, their Human Development Index, levels of social vulnerabilities, conditions of violence, and work opportunities¹⁴14. Sousa A, Dal Poz MR, Boschi-Pinto C. Reducing inequities in neonatal mortality through adequate supply of health workers: evidence from newborn health in Brazil. PLoS One 2013; 8(9):e74772.,²¹21. Scheffer M, Cassenote A, Biancarelli A. Demografia Médica No Brasil. São Paulo: FMUSP; 2015.,³³33. Póvoa L, Andrade MV. Geographic distribution of physicians in Brazil: an analysis based on a locational choice model. Cad Saude Publica 2006; 22(8):1555-1564.,³⁶36. Maciel Filho R. Estratégias para a distribuição e fixação e médicos em sistemas nacionais de saúde: o caso brasileiro [tese]. Rio de Janeiro: UERJ; 2007.; individual characteristics, for example age, work opportunities for spouses, origin in urban environments and family income³³33. Póvoa L, Andrade MV. Geographic distribution of physicians in Brazil: an analysis based on a locational choice model. Cad Saude Publica 2006; 22(8):1555-1564.,³⁹39. Kirk JM, Kirk EJ, Mary S. Mais Médicos: Cuba’s Medical Internationalism Programme in Brazil. Bull Lat Am Res 2015; 35(4):467-480.; characteristics of the education system, existence of a medical course, medical residency and possibilities of continued education²¹21. Scheffer M, Cassenote A, Biancarelli A. Demografia Médica No Brasil. São Paulo: FMUSP; 2015.,³³33. Póvoa L, Andrade MV. Geographic distribution of physicians in Brazil: an analysis based on a locational choice model. Cad Saude Publica 2006; 22(8):1555-1564.,³⁶36. Maciel Filho R. Estratégias para a distribuição e fixação e médicos em sistemas nacionais de saúde: o caso brasileiro [tese]. Rio de Janeiro: UERJ; 2007.; and finally organizational characteristics including remuneration, working conditions, career plan and professional recognition²¹21. Scheffer M, Cassenote A, Biancarelli A. Demografia Médica No Brasil. São Paulo: FMUSP; 2015.,⁴⁰40. Pierantoni CR. Fortalecimento da Capacidade de Planejamento de Recursos Humanos para Sistemas Nacionais de Saúde. Belo Horizonte: UFMG; 2013..

II - Strategies put in place to deal with the problem of scarcity and distribution

In 2003 the Brazilian Health Ministry created the Health Work & Education Management Department (SGTES), and now carries out a strategic role: it is responsible for formulation of policies for management of work in health; training and qualification of healthcare human resources; professional regulations; and decentralization of management of work and education in the states of Brazil⁴¹41. Pierantoni CR, Garcia ACP. Human resources for health and decentralization policy in the Brazilian health system. Hum Resour Health 2011; 9:12.. Over recent years the subject of healthcare human resources, and in particular as regards geographical availability and accessibility, has been recurring and is closely related to the difficulties faced in the health sector. Analyzing the continuity of this subject, documents providing orientation on the interventions in health are seen as from the National Health Plans of 2004-2007, 2008-2011 and 2012-2015⁴²42. Brasil. Ministério da Saúde (MS). Portaria nº 2.607, de 10 de dezembro de 2004. Aprova o Plano Nacional de Saúde/PNS – Um Pacto pela Saúde no Brasil. Diário Oficial da União 2004; 11 dez.

43. Brasil. Ministério da Saúde (MS). Plano Nacional de Saúde/PNS 2008/2009-2011. Brasília: MS; 2009.-⁴⁴44. Brasil. Ministério da Saúde (MS). Plano Nacional de Saúde – PNS 2012-2015. Brasília: MS; 2011., the National Basic Healthcare Policy²⁵25. Brasil. Ministério da Saúde (MS). Política Nacional de Atenção Básica. Vol I; 2012. [acessado 2016 fev 10]. Disponível em: http://189.28.128.100/dab/docs/publicacoes/geral/pnab.pdf
http://189.28.128.100/dab/docs/publicaco... , and Resolution 439 of the National Health Council⁴⁵45. Brasil. Ministério da Saúde (MS). Resolução nº 439, de 7 de abril de 2011. Diário Oficial da União 2011; 8 abr., constituting a synergy in relation to the problem. However, it is seen that there is something lacking in the formulation of a clear, long-term policy to govern healthcare human resources in Brazil³¹31. Buchan J, Fronteira I, Dussault G. Continuity and change in human resources policies for health: lessons from Brazil. Hum Resour Health 2011; 9(1):17., even though several specific and limited strategies have been identified for facing these challenges.

The interventions identified were:(a) the Rondon Project (Projeto Rondon); (b) the Interiorization Program of the SUS (Programa de Interiorização do SUS – or PISUS); (c) the Program to Move Health Work into the Interior (Programa de Interiorização do Trabalhoem Saúde – or PITS), (d) Telessaúde (‘Tele-Health’); (e) the Program to Support Training of Specialist Doctors in Strategic Areas (Programa de Apoio à Formação de Médicos Especialistas em Áreas Estratégicas – ‘Pró-Residência’); (f) the Fund for Financing Higher Education Students (Fundo de Financiamento ao Estudante do Ensino Superior – or FIES); (g) the Program to Value Basic Healthcare Professionals (Programa de Valorização dos Profissionais da Atenção Básica– or PROVAB); and (h) the ‘More Doctors’ (MaisMédicos) Program – described in Chart 3.

In the policy initiatives that were implemented, there are superimpositions of its possible results on various fronts of the problems being dealt with, and we thus present the findings relating the initiative, the challenge (geographical availability and distribution) and the policy area, according to the logic of the conceptual framework of the employment market and policy interventions in health¹²12. Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bull World Health Organ 2013; 91(11):892-894.. The approaches are illustrated in Chart 4.

Discussion

Considering the health system implemented in Brazil, it is certainly a challenge for policy makers and managers to ensure availability and accessibility to health for the whole of the population. Another challenge is the growing increase in the demand for health professionals, both in the public and in the private sector, attributed principally to the expansion of the service network. Studies show that among the principal challenges are scarcity of doctors, and their inadequate distribution, both by geographical area and between levels of care.

As to scarcity, one sees that it is often difficult to quantify it, perhaps due to the lack of knowledge of present and future needs for doctors. Thus, an integrated analysis has been substituted by comparison using external benchmarks in an isolated form, comparing with other countries, without knowing whether these are appropriate for the Brazilian health system. The documents that were selected attribute the causes of scarcity as principally being demand for professionals and training, to the detriment of other elements such as inflow (example: immigration, and people returning from another sector) and outflow (e.g. termination of career, and retirement).

Scarcity exacerbates the difficulty of management of the distribution of doctors between the regions of the country and between the levels of care¹⁵15. Campos FE. Funding, flexible management needed for Brazil’s health worker gaps. Interview by Claudia Jurberg. Bull World Health Organ 2013; 91(11):806-807.. Geographical distribution is a problem that has long been diagnosed in Brazil and was significantly reported in the studies selected, showing that doctors are indeed concentrated in the South and Southeast, in major cities and in the more developed municipalities. However, wider and deeper analyses are necessary about the factors that could lead doctors to migrate to work in regions that are lacking care. The literature indicates that to become aware of these factors priority should be given to qualitative studies and Discrete Choice Experiments (DCE) – which as well as awarding points for isolated factors make it possible to identify the preferences of individuals based on comparisons between certain characteristics of the work since some benefits in the employment contract can be a counterpart to the location of the work³²32. Dal Poz MR. The health workforce crisis. Cad Saude Publica 2013; 3(10):1924-1926.,⁴⁶46. World Health Organization (WHO). How to conduct a discrete choice experiment for health workforce recruitment and retention in remote and rural areas: a user guide with case studies. Geneva: WHO; 2012..

Inadequate distribution between the levels of care, on its own, does not present a precise diagnosis in Brazil, but points to various factors: scarcity of doctors in primary care; concentrations of specialists in the private sector; and unequal distribution of some specialties in the regions of the country. The studies indicate that for primary healthcare and consequently the Family Health Strategy to be more effective in providing solutions, in relation to availability of doctors, various challenges need to be met, including the problem of turnover and lack of confirmed permanent residence of these professionals⁴⁷47. Ney MS, Rodrigues PH de A. Fatores críticos para a fixação do médico na Estratégia Saúde da Família. Physis 2012; 22(4):1293-1311.. This situation can be attributed to the low levels of stimuli in temporary work contracts⁵³53. Canesqui AM, Spinelli MAS. A implementação do Programa Saúde da Família em municípios do Estado de Mato Grosso, Brasil. Cad Saude Publica 2008; 24(4):862-870., which in turn are often the result of budget restrictions of municipalities that are unable to adjust doctors’ salaries enough to retain them, since that adjustment would infringe the Fiscal Responsibility Law⁵⁴54. Camargo Júnior KR, Campos EMS, Bustamante-Teixeira MT, Mascarenhas MTM, Mauad NM, Franco TB, Ribeiro LC, Alves MJM. Avaliação da atenção básica pela ótica político-institucional e da organização da atenção com ênfase na integralidade. Cad Saude Publica 2008; 24(Supl. 1):s58-s68.. Additionally, studies point to structure problems, related to the process of work. The Family Health Strategy, and Primary Healthcare, should be organized in an equitable and efficient fashion to achieve their potential in facing the challenges imposed on health²⁴24. Organização Pan-Americana de Saúde (OPAS). Renovação da Atenção Primária em Saúde nas Américas. Brasília: OPAS; 2007., but one still sees teams rooted in the traditional medical-hegemony model, which contributes to excess workload for the professional⁶³63. Gomes FM, Silva MGC. Family health program as a strategy of primary attention: a reality at Juazeiro do Norte. Cien Saude Colet 2011; 16(Supl. 1):893-902. without giving priority to multi-professional teamwork. On the other hand, although it is not its central aim, the Family Health Strategy can be considered to be the initiative that has most expanded the coverage of doctors³²32. Dal Poz MR. The health workforce crisis. Cad Saude Publica 2013; 3(10):1924-1926., contributing to improvement of accessibility to health services. In secondary care, on the other hand, the difficulty is attributed to contracting of specialists to work in the SUS⁹9. Scheffer MC, Dal Poz MR. The privatization of medical education in Brazil: trends and challenges. Hum Resour Health 2015; 13(1):96.,⁶⁴64. Carvalho CL, Petta HL, Araújo JF, Girardi Junior JB, Oliveira VA. Avaliação nacional da demanda de médicos especialistas percebida pelos gestores de saúde. Belo Horizonte: EPSM; 2009..

The inadequate geographical distribution of doctors is a problem that has been present on the policy decision agenda for various governments in Brazil¹⁰10. Campos FE, Machado MH, Girardi SN. A fixação de profissionais de saúde em regiões de necessidades. Divulg em Saúde para Debate 2009; 44(maio):13-24.,³²32. Dal Poz MR. The health workforce crisis. Cad Saude Publica 2013; 3(10):1924-1926.. Starting in 2011 the deficit in provision of professionals was defined as a priority area³⁷37. Brasil. Ministério da Saúde (MS). Programa Mais Médicos – Dois Anos: Mais Saúde para os Brasileiros. Brasília: MS; 2015.. Initiatives to deal with the challenge of inadequate distribution have been put in place since 1968. On the other hand implementation of initiatives for the problem of scarcity is more recent, with only two measures identified, Pró-Residência and the PMM. According to information presented (Charts 3 and 4) initial programs failed in their sustainability on a time horizon, although the pioneer program was re-established some 35 years later.

It can be seen from the analysis (Chart 4) that since 2011, with the PROVAB, the initiatives incorporated a larger number of strategies and although there are not yet evaluations of their impacts, considering the conceptual table used (Figure 1), it can be inferred that there is a greater possibility of success since the evidences on the subject indicate that initiatives carried out jointly are more efficacious than isolated ones⁸8. Kroezen M, Dussault G, Craveiro I, Dieleman M, Jansen C, Buchan J, Barriball L, Rafferty AM, Bremner J, Sermeus W. Recruitment and retention of health professionals across Europe: a literature review and multiple case study research. Health Policy 2015; 119(12):1517-1528.. It was observed that the policy initiatives are concentrated on distribution, with focus on primary care, neglecting distribution between other levels of care, perhaps for lack of a clearer diagnosis. Only the Pró-Residência program was identified as a program with effect in this regard.

The absence of evidence from actual research results to contribute to a diagnosis for the inadequate distribution of doctors between the levels of care, and its causes, makes it difficult to formulate initiatives that are informed by evidence, thus increasing the risk of their being formulated in an improvised manner or having their process dominated by other factors than evidence.

In graduation courses, the articulation between teaching and service is reported in various studies. The dynamic between these subjects is justified by the quest for professionals with necessary competencies to act in the SUS, that is to say, the training should prepare the professional to work based on the principles, guidelines and policies of the health system that is in force⁶⁶66. Brasil. Ministério da Educação (MEC). Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina. Brasília: MEC; 2014.. There are programs put in place for reorientation of professional training: highlights are the IDA Project, the Uni and Rede Unida project, prior to the creation of SGTE; and, subsequent to the SGTEs being put in place⁶⁷67. Dias H, Lima L, Teixeira M. A trajetória da política nacional de reorientação da formação profissional em saúde no SUS. Cien Saude Colet 2013; 18(6):1613-1624.: the PROMED, Ver SUS, Aprender SUS, Ensina SUS, Pró-Saúde (I and II), PET-Saúde and the National Permanent Education Policy. At the same time, there are situations where these articulations are fragile and there is a lack of planning and coordination between the need for training and the population demand²⁹29. Jesus LE, Aguiar AS, Campos MSM, Baratella JRS, Ketzer JC, Mastroti RA, Amarante ACM. Formação e demanda do cirurgião pediátrico no Brasil. Rev Col Bras Cir 2009; 36(4):356-361..

Among the initiatives identified for facing the challenges, which are the focus of this study, the PMM is the one that has the most cross-sectional action, dealing with all the challenges identified in this review, and having strategies in almost all the four areas of policy intervention, only not acting in one area: regulation of the private sector.

The process of formulation of a policy can be influenced by various factors⁶⁸68. Lavis JN, Ross SE, Hurley JE, Hohenadel JM, Stoddart GL, Woodward CA, Abelson J. Examining the role of health services research in public policymaking. Milbank Q 2002; 80(1):125-154.. Among these, scientific evidence can play an important role, since it helps policymakers and other actors to take well-informed decisions about policies, programs and projects so as to guarantee that the decision made is well informed by the best research evidence available⁶⁹69. Oxman AD, Lavis JN, Lewin S, Fretheim A. SUPPORT Tools for evidence-informed health policymaking (STP) 1 : what is evidence-informed policymaking? Heal Res Policy Syst 2009; 7(1):1-7., thus avoiding domination of the process by other factors.

When we evaluate the results of the efforts to highlight the use of evidence in formulation of policies, we should go beyond questioning whether the evidence was used in the process, to find out when it was used⁷⁰70. Lavis JN. Research, public policymaking, and knowledge-translation processes: Canadian efforts to build bridges. J Contin Educ Health Prof 2006; 26(1):37-45.,⁷¹71. Hanney SR, Gonzalez-Block MA, Buxton MJ, Kogan M. The utilisation of health research in policy-making: concepts, examples and methods of assessment. Heal Res Policy Syst 2003; 1(1):2.; for what purpose⁷²72. Weiss CH. The Many Meanings of Research Utilization. Public Adm Rev 1979; 39(5):426.

73. Lavis JN, Robertson D, Woodside JM, McLeod CB, Abelson J. How can research organizations more effectively transfer research knowledge to decision makers? Milbank Q. 2003; 81:171-172-248.-⁷⁴74. Trostle J, Bronfman M, Langer A. How do researchers influence decision-makers? Case studies of Mexican policies. Health Policy Plan 1999; 14(2):103-114.; and what approach was used to promote its use⁷³73. Lavis JN, Robertson D, Woodside JM, McLeod CB, Abelson J. How can research organizations more effectively transfer research knowledge to decision makers? Milbank Q. 2003; 81:171-172-248.,⁷⁵75. Lomas J. Using “linkage and exchange” to move research into policy at a Canadian foundation. Health Aff 2000; 19(3):236-240.,⁷⁶76. Lavis JN, Lomas J, Hamid M, Sewankambo NK. Assessing country-level efforts to link research to action. Bull World Health Organ 2006; 84(8):620-628.. In this study, according to the message chosen, it is possible only to observe the possibility of the use of the evidence in the phases of the policy cycle in accordance with the type of research/survey available.

The most common approach for studying public policies, the “policy cycle”, breaks down the political process into a series of functional stages (creation of the agenda, development of the formulation of the policy, implementation and assessment)⁷⁷77. Pollard A, Court J. How Civil Society Organizations Use Evidence to Influence Policy Processes: A Literature Review. London: Shaping Policy for Development; 2005.,⁷⁸78. Walt G, Shiffman J, Schneider H, Murray SF, Brugha R, Gilson L. “Doing” health policy analysis: methodological and conceptual reflections and challenges. Health Policy Plan 2008; 23(5):308-317.. Scientific evidence can play a significant role in all the phases of the cycle. However, for each phase there is also a type of research, and a research question, that is most appropriate and relevant to that moment⁷⁰70. Lavis JN. Research, public policymaking, and knowledge-translation processes: Canadian efforts to build bridges. J Contin Educ Health Prof 2006; 26(1):37-45.,⁷¹71. Hanney SR, Gonzalez-Block MA, Buxton MJ, Kogan M. The utilisation of health research in policy-making: concepts, examples and methods of assessment. Heal Res Policy Syst 2003; 1(1):2..

The demand by policy formulators for research in the area of Healthcare Human Resources cannot be considered insufficient in Brazil, as can be seen by the volume of research funding available in the country, from the fact that Healthcare Human Resources is among the priority research areas of the National Research and Health Agenda⁷⁹79. Brasil. Ministério da Saúde (MS). Agenda Nacional de Prioridades de Pesquisa Em Saúde. 2ª ed. Brasília: MS; 2011., and also from the collaboration of the Human Relations Observatory Network in Brazil (ObservaRH) with the SGTES, an initiative sponsored by the Health Ministry, together with the Technical Cooperation Program of the Pan-American Health Organization (PAHO) of the WHO ⁸⁰80. ObservaRH. Rede Observatório de Recursos Humanos em Saúde no Brasil: Repertório com a Produção da Rede ObsevaRH- Brasil. [acessado 2016 fev 1]. Disponível em: http://www.observarh.org.br/observarh/repertorio/index.htm. Accessed March 10, 2015.
http://www.observarh.org.br/observarh/re... . However, the focus of these surveys identified through the articles selected in the Brazilian context concentrates on the description of the problems, the diagnosis and its causes, and there is an absence of investigations that analyze alternatives and solutions for reduction of the problem concerned in a critical way, or assessment of alternatives implemented in other countries in light of the Brazilian context. Thus it can be asked whether there is a difficulty in communication between formulators of policy and researchers (which is reflected in the research questions being different from the need for reply from policy makers for intervention in the policy in question), or whether the means of disclosure is different from the ‘conventional’ medium of publication of articles?

Since this study is based on the analysis of documents there are limitations, especially as to the reach of the context of healthcare HR policies in Brazil. For this reason, an additional phase of the study is being developed, which consists of interviews with the makers of policy and researchers among other key actors.

Final considerations

When we relate the challenges to the initiatives implemented, it is seen that the governments were looking for solutions to ensure geographical availability and accessibility to doctors in the SUS. And they looked mainly at measures identified in other countries and recommended for application, with variations as to the strength of recommendations, arising from the evidence¹⁷17. World Health Organization (WHO). Increasing Access to Health Workers in Remote and Rural Areas through Improved Retention. Geneva: WHO; 2010.. However, our analyses show that no policy initiatives were found in the areas of regulation of the private sector, showing that there is a need for initiatives and policies that consider all the facets of the health employment market in Brazil, such as, for example, the coexistence between the public and private sector. Equally, it is desirable that there should be execution of monitoring and assessments of the results achieved and the subsequent impact generated. Based on the evidences and the present context of health in Brazil, it is noted that policies directly made for human relations are essential for guaranteeing geographical accessibility for medical care in the SUS and for sustainability of the initiatives that have been put in place.

Acknowledgments

This article is part of a doctoral research project supported by CNPq (Ciência sem Fronteira). Funds were also received for part of the survey from FAPERJ (Cientista do Nosso Estado).The authors thank Professor John N Lavis for valuable commentaries on the method, and the advisory consultant sources for their help in the process of identifying strategies, providing documents and valuable comments.

References

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History