Abstract

Introduction

Health policy-making informed by the best available scientific evidence helps policy-makers make more assertive decisions ¹1. Oxman AD, Lavis JN, Lewin S, Fretheim A. SUPPORT Tools for evidence-informed health Policymaking (STP) 1: what is evidence-informed policymaking? Health Res Policy Syst 2009; 7 Suppl 1:S1.. It is characterized by transparent assessment of the relevant research, aimed at guaranteeing that others can determine which evidence was used appropriately ¹1. Oxman AD, Lavis JN, Lewin S, Fretheim A. SUPPORT Tools for evidence-informed health Policymaking (STP) 1: what is evidence-informed policymaking? Health Res Policy Syst 2009; 7 Suppl 1:S1.. The potential advantages are: better structuring of policy-making rather than sole determination by the main actors ²2. Strydom WF, Funke N, Nienaber S, Nortje K, Steyn M. Evidence-based policymaking: a review. S Afr J Sci 2010; 106:1-8.^,33. Campbell S, Benita S, Coates E, Davies P, Penn G. Analysis for policy: evidence-based policy in practice. http://preval.org/files/pu256_160407.pdf (acessado em 30/Dez/2016).
Analysis for policy: evidence-based poli... ; helping the public at large and decision-makers understand a problem and choose the most appropriate policy alternatives; achieving greater transparency in the use of public funds; and reducing or avoiding the risk of the policy’s failure ³3. Campbell S, Benita S, Coates E, Davies P, Penn G. Analysis for policy: evidence-based policy in practice. http://preval.org/files/pu256_160407.pdf (acessado em 30/Dez/2016).
Analysis for policy: evidence-based poli... . Meanwhile, failure to use evidence can lead to underutilization of effective interventions, incorrect use of adequate interventions, and excessive use of unproven interventions ⁴4. Ward V, House A, Hamer S. Developing a framework for transferring knowledge into action: a thematic analysis of the literature. J Health Serv Res Policy 2009; 14:156-64.^,55. Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, et al. Lost in knowledge translation: time for a map? J Contin Educ Health Prof 2006; 26:13-24.. This scenario can create serious consequences for users of services, such as jeopardizing access to adequate healthcare, increasing health inequalities ¹, and inefficient use of limited resources for healthcare provision ⁶6. World Health Organization. World report on knowledge for better health: strengthening health systems. Geneva: World Health Organization; 2004..

Despite progress in the last 20 years in the use of evidence, not all the lessons learned in policies related to clinical practice can necessarily be applied to other areas. Some review studies have examined the factors that hinder (vs. facilitate) the use of scientific evidence for informing policy decisions in legislative and administrative areas in the health sector ⁷7. Oliver K, Innvar S, Lorenc T, Woodman J, Thomas J. A systematic review of barriers to and facilitators of the use of evidence by policymakers. BMC Health Serv Res 2014; 14:2.^,88. Innvaer S, Vist G, Trommald M, Oxman A. Health policy-makers' perceptions of their use of evidence: a systematic review. J Health Serv Res Policy 2002; 7:239-44.. Few studies have examined the use of scientific evidence in the policy-making process in a context of competing influences ⁹9. Waddell C, Lavis JN, Abelson J, Lomas J, Shepherd CA, Bird-Gayson T, et al. Research use in children's mental health policy in Canada: maintaining vigilance amid ambiguity. Soc Sci Med 2005; 61:1649-57.. The use of evidence in policy-making could be improved if researchers knew the competing influences in the political process, formed partnerships with the decision-makers, questioned the incentives from research institutions, and engaged in the public debate on the research problems ⁹9. Waddell C, Lavis JN, Abelson J, Lomas J, Shepherd CA, Bird-Gayson T, et al. Research use in children's mental health policy in Canada: maintaining vigilance amid ambiguity. Soc Sci Med 2005; 61:1649-57..

This study aims to analyze whether the policy decisions for human resources for health that aim to improve the geographic distribution of physicians have been informed by scientific evidence in Brazil and Portugal. More specifically, the study aims to identify and analyze the factors that influence policy-making for human resources for health that aim to improve the geographic distribution of physicians, the efforts to use evidence in these policy decisions, and strategies used to improve human resources for health policies, informed by scientific evidence.

Method

This is a multiple case study on the policy-making process for human resources for health in Brazil and Portugal, developed in three phases: (I) and (II) analysis of the political contexts for human resources for health in the two countries ¹⁰10. Oliveira APC, Gabriel M, Dal Poz MR, Dussault G. Desafios para assegurar a disponibilidade e acessibilidade à assistência médica no Sistema Único de Saúde. Ciênc Saúde Coletiva 2017; 22:1165-80.^,1111. Oliveira APC, Dussault G, Craveiro I. Challenges and strategies to improve the availability and geographic accessibility of physicians in Portugal. Hum Resour Health 2017; 15:24. and (III) the focus of this article, analysis of the policy-making process and the factors that influenced it, from the perspective of the respective actors.

The policies were selected because they have the same objective of reducing the asymmetrical distribution of physicians in areas with unmet needs for health services (rural, remote, and/or poor areas) and because they are implemented mainly in primary healthcare (PHC) (Table 1).

Data collection and sampling

From November 2015 to April 2016, face-to-face semi-structured interviews were conducted by the first author with key actors in the policy-making process for the target policies. A total of 27 actors were interviewed out of 35 requests that were sent (“snowball approach”), after a maximum of three attempts at contacts, so 8 actors were not interviewed (6 Brazilians and 2 Portuguese). The interviewed actors belonged to one of the three groups in Table 2.

A semi-structured questionnaire was used with the following topics: the policy’s history, factors that influenced the policy-making, actors who were expected to gain or lose with the implementation, scientific evidence and available data used for the policy-making, and mechanisms promoted by the Ministry of Health to facilitate the use of and access to research results. Interviews focused on the interviewees’ personal perceptions and experiences in the policy process and do not express the views of the institution or the position occupied by the actor.

Analysis of the interviews

The interviews were recorded and transcribed. The analysis of the collected data used the 3Is (Interests, Ideas, and Institutions) conceptual framework, including External Factors (3Is+E) (Figure 1).

The framework is based on three factors that the political science literature uses to explain the public policy development process ¹²12. Lavis JN, Rottingen JA, Bosch-Capblanch X, Atun R, El-Jardali F, Gilson L, et al. Guidance for evidence-informed policies about health systems: linking guidance development to policy development. PLoS Med 2012; 9:e1001186.^,1313. Pomey M-P, Morgan S, Church J, Forest P-G, Lavis JN, McIntosh T, et al. Do provincial drug benefit initiatives create an effective policy lab? The evidence from Canada. J Health Polit Policy Law 2010; 35:705-42.. The principle is that the policy’s development and choices can be influenced by the actors’ interests and ideas and the institutions’ configuration ¹²12. Lavis JN, Rottingen JA, Bosch-Capblanch X, Atun R, El-Jardali F, Gilson L, et al. Guidance for evidence-informed policies about health systems: linking guidance development to policy development. PLoS Med 2012; 9:e1001186.^,1313. Pomey M-P, Morgan S, Church J, Forest P-G, Lavis JN, McIntosh T, et al. Do provincial drug benefit initiatives create an effective policy lab? The evidence from Canada. J Health Polit Policy Law 2010; 35:705-42. (Table 3).

The thematic data analysis occurred deductively through predetermined categories and subcategories proposed in the conceptual framework and inductively with subcategories that emerged from the reading of the transcribed interviews.

Ethical aspects

The study was approved by the Institutional Review Board of the Institute of Social Medicine of the State University of Rio de Janeiro, Brazil (CAAE:49733215.4.0000.5260) and the Ethics Council of the Institute of Hygiene and Tropical Medicine of the New University of Lisbon, Portugal.

Results and discussion

The results are organized in subsections with the research objectives in order to allow comparisons.

Factors that influenced the policy decisions for the strategies in Brazil and Portugal

The factors that appeared most often in the interviews as having influenced the More Doctors Program (PMM, in Portuguese) were (Ia) Institutions, with the subcategories referring to government structure and policy legacy; (Ib) External Factors (Presidential elections); (Ic) group Interests (mayors and medical associations), governments (Brazil and Cuba), international organization (Pan American Health Organization - PAHO) and civil society; and Ideas (scientific evidence). The most frequently cited factors in the interviews in Portugal were (IIa) Institutions, policy legacies, and government structure and (IIb) Interests of governments (the Portuguese government and those of countries involved in the bilateral agreements), civil society and groups (medical associations). See Table 4 for examples of quotes by the interviewees.

Ia - Institutional factors in the PMM (Brazil)

In relation to government structure, policy-makers reported that the internal difficulties in the Ministry of Health, bureaucratic issues, and centralization of the policy process and program deployment in a country the size of Brazil all hindered the policy process (BR_PM1). According to the policy-makers, the Ministry of Health played the role of designing, coordinating, and implementing the PMM and leading the changes in the physicians’ training process, together with the Ministry of Education and the Office of the Chief of Staff. The process also involved the Brazilian Ministry of Foreign Relations, Ministry of Defense, Internal Revenue Service, Federal Police, Ministry of Labor and Employment, and Bank of Brazil (BR_Staff/BR_PM1). The Ministry of Health’s role in providing the guidelines and policy decisions was challenged by interviewees in the interest group, according to whom the Ministry of Health, with the PMM, began to adopt an operational role, contradicting the organization of the Brazilian Unified National Health System (SUS) and indicating a possible re-centralization of healthcare activities (BR_CS1).

According to the policy-makers, policy legacies gave impetus to and shaped the policy process and also mitigated the difficulties. The process drew on a principle from Article 200 of Brazil’s 1988 Federal Constitution, according to which the SUS has the mandate to organize human resources for health training. This mandate provided the basis for the additional interventions in the training and continuing education programs, namely expanding the areas of policy intervention used to act on the issue of distribution of physicians in the country (BR_PM2).

The policy-makers and interest group actors also emphasized the importance of programs that preceded the PMM and aimed to correct the uneven distribution of physicians. The Program for Territorial Decentralization of the SUS (PISUS) and Program for Territorial Decentralization of Healthcare Work (PITS) helped demonstrate that isolated interventions tend not to spawn long-term sustainability, and that multiple interventions in different policies are needed to achieve the objectives and sustainability. The experience with these programs was short-lived, involving a limited number of health professionals, and they failed to change crucial issues in the medical training process (BR_CS1/BR_PM1/BR_PM2).

More recent programs strengthened the Ministry of Health’s institutional capacity, which proved essential for developing the conditions to design and implement the PMM. These previous experiences allowed greater agility and scale for the implementation of the PMM (BR_PM2/BR_Staff).

Ib - External Factors to the PMM (Brazil)

As for External Factors, nearly all of the interest group actors mentioned the Presidential election as a factor that influenced the PMM, citing the need for a quick policy and program that could be identified as the Administration’s brand in the health area.

Ic - The Interests factor in the PMM (Brazil)

According to the three groups of interviewees, the actors that gained the most with the program were: governments (Cuba and Brazil), mayors of the municipalities served by the PMM; civil society, and PAHO. The Brazilian medical profession was identified as a potential loser.

According to the policy-makers, the initial milestone of the PMM took place when a new Minister of Health took office: in his first few months in office in 2011, he organized a national seminar in Brasília on the shortage, provision, and retention of health professionals in remote and more vulnerable areas. In addition, the Multi-annual Plan and the National Primary Health Care Policy (PNAB), central pillars in the organization of the SUS, cited a shortage of physicians as one of the difficulties for upgrading and expanding primary healthcare, showing that this issue would be a priority on the health policy agenda at the time.

According to the policy-makers, the PMM was a political decision by the President of Brazil, who in February 2012 mandated the Ministry of Health to design a program capable of increasing the supply and quality of physicians in PHC. The issue was discussed for a year and five months, during which time information was gathered for organizing a diagnosis, proposing interventions, and identifying priority places for action. The possibility of cooperation with Cuba began to materialize in April 2013 (BR_Staff).

Also according to policy-makers, in early 2013 the Program for Valorization of Primary Care Professionals (PROVAB) filled 3,500 vacancies, but the demand from local governments was for 13,000 physicians. At the time, one of the factors cited in nearly all of the interviews (as one of the most important at the time), the National Coalition of Mayors (FNP), launched a campaign called “Where’s the Doctor?”. The FNP appreciated and drew on previous initiatives such as the Fund for Financing Students in Higher Education (FIES) and PROVAB, while emphasizing that more action was needed. To advocate for a solution to the problem, the mayors relied on non-systematic or unstructured evidence (BR_PM1).

Most of the interviewees cited the protests by Brazilian civil society in June and July 2013, spearheaded by the “20-Cents March” (against a fare hike in municipal buses), as catalysts for the policy ¹⁴14. Oliveira JPA, Sanchez MN, Santos LMP. O Programa Mais Médicos: provimento de médicos em municípios brasileiros prioritários entre 2013 e 2014. Ciênc Saúde Coletiva 2016; 21:2719-27.. Health was a key issue on the national agenda, and the demands included quality improvement and expansion of access to services (BR_PM3). One of the actors in the interest group also identified this time as a window of opportunity for human resources for health policy in Brazil, which was subsequently confirmed (BR_CS1).

The Cuban government and PAHO were also identified as winners in the program’s policy-making. According to the interest group actors, the program was initially conceived as a political agreement between the government of Cuba and the government of Brazil with participation by PAHO, with specific characteristics of economic cooperation (BR_IO). There was an increase in PAHO’s relevance in the organization’s interaction with the Brazilian government (BR_IO).

Finally, interviewees showed some reluctance in identifying the actors that stood to lose from the program’s policy. The policy-makers stated that up to a certain point the medical associations, especially the National Federation of Physicians, Brazilian Medical Association, and Federal Board of Medicine (CFM), supported initiatives like PROVAB. Still, although the policy-makers and some interest group actors did not see the program as harmful to Brazilian physicians’ employability or income (referring to the emergency component of hiring foreign physicians), as perceived by these actors, the medical associations as a whole proved resistant and fearful that they might lose from the implementation of the PMM (BR_PM1). One interest group actor also identified an unexpected final gain for Brazilian physicians, who wanted the PMM physicians to cover unserved areas of the country (BR_IO).

Lobbying by medical associations against the PMM led to a change. The policy’s initial version included the “second cycle in medicine”, which consisted of extending the course of medicine for two more years to include an internship in PHC. In the face of the resistance, this intervention was changed.

IIa - Institutional factors in the bilateral agreements (Portugal)

As an institutional factor (policy legacies), the past experience with the bilateral agreement with the Uruguayan government for provision of emergency medical services was cited as a factor that influenced subsequent policy decisions. The possibility of this agreement was identified by the exchange of experiences between health policy-makers from both governments in an Ibero-American meeting, and the policy-making process began in 2005 and 2006, while the policy was implemented in 2008. Portugal’s part of the agreement was to train physicians and nurses in liver transplantation during a year at the Curry Cabral Hospital in Lisbon and to provide support by the Portuguese team in the first liver transplants performed in Uruguay. Based on this experience, in 2008 the Portuguese government commissioned a plan for hiring foreign physicians, to be designed by the person responsible for executing the bilateral agreement with the government of Uruguay (PT_PM3/PT_PM4).

Another facilitating factor cited by a policy-maker (from government) was the fact that the process was developed in the Ministry of Health and concentrated in a single policy-maker with direct access to the Minister (PT_PM3).

IIb - The Interest factor in the bilateral agreements (Portugal)

According to the interviewees, the actors that gained the most with the bilateral agreements were the governments and civil society. A potential “loser” that was identified was the medical profession, represented by the medical associations.

In relation to the interest factor, the policy process was identified by policy-makers as indispensable as a political need and the population’s need (PT_PM3). As for the population’s need, there was a large share of the Portuguese population without designated family physicians, which hindered the development of a reform program in PHC. Various isolated and ad hoc strategies were employed to deal with this problem, such as the implementation of a 25% quota for places in medical residency for family physicians. According to the policy-makers interviewed in this study, these strategies failed to produce an adequate short-term response, which required an intervention that would have obtained a “more immediate” response than training physicians (PT_PM2). But according to the interested actors, the bilateral agreements did not involve a significant number of physicians and were implemented to solve isolated problems in regions like the Alentejo and Algarve (PT_EM1).

According to the policy-makers, the decision to hire physicians from Latin America was due to the impossibility of hiring physicians from European countries, which was Portugal’s original choice due to the diploma’s automatic validation. However, physicians’ salaries in some of these countries are at least as high as in Portugal, while the cost of living is lower (e.g., Poland), and other European countries with shortages of physicians, like England, Finland, Sweden, Norway, and Germany, offer more attractive conditions (PT_PM2).

All the bilateral agreements included a counterpart role for the government of Portugal, except for the agreement with Costa Rica, where the negotiation was done with the Medical Council, which did not require it. Cuba received financial compensation specifically as an amount paid to the Cuban government for physicians with experience in the Community of Portuguese-Speaking Countries (CPLP) to provide healthcare in Portugal for three years. In the case of Colombia, Portugal’s part was an agreement between universities by which students would conduct research projects and Master’s and PhD theses between Portugal and Colombia, in Portugal.

According to the policy-makers, the Order of Physicians showed some resistance to the strategy, although Portuguese physicians were identified as actors that did not stand to lose from the policy, since the bilateral agreements provided that the foreign doctors would work in the country for three years, after which they would return to their own countries. The argument employed in the political opposition to the government was that Portugal was not short on doctors, but that the doctors were poorly distributed. As indicated by one of the policy-makers, this rhetoric had prevented effective political action for years (PT_PM2).

Ideas factor

The problem of geographic distribution of physicians is not exclusive to Brazil and Portugal and has been the subject of hot debate by academia for at least ten years. Although a series of possible strategies have been identified with greater or lesser strength of evidence ¹⁵15. Chopra M, Munro S, Lavis JN, Vist G, Bennett S. Effects of policy options for human resources for health: an analysis of systematic reviews. Lancet 2008; 371:668-74.^,1616. World Health Organization. Transforming and scaling up health professionals' education and training: World Health Organization guidelines 2013. Geneva: World Health Organization; 2013.^,1717. World Health Organization. Increasing access to health workers in remote and rural areas through improved retention. Geneva: World Health Organization; 2010., there is no single model that can be implemented by any country and guarantee a solution to the problem. It is thus necessary to understand the problem’s causes, the characteristics and needs of the country’s system and health professionals, in order to make the policy choice and the necessary adjustments in the selected set of strategies.

The use of scientific evidence in policy-making is a complex process, not always systematic or transparent, and influenced by numerous factors, since decision-making is not an exclusively technical process, but is also inherently social ¹1. Oxman AD, Lavis JN, Lewin S, Fretheim A. SUPPORT Tools for evidence-informed health Policymaking (STP) 1: what is evidence-informed policymaking? Health Res Policy Syst 2009; 7 Suppl 1:S1.^,1212. Lavis JN, Rottingen JA, Bosch-Capblanch X, Atun R, El-Jardali F, Gilson L, et al. Guidance for evidence-informed policies about health systems: linking guidance development to policy development. PLoS Med 2012; 9:e1001186.. The complexity of this process, specifically that of policy-making for human resources for health, has increased in recent years due to the number of actors involved and the growth in scientific evidence, both in volume and complexity. As revealed by the interviews, research is not the only factor that influences policy decisions, and we thus need to understand the policy-making process as a whole in order to understand the research needs and the moment in which it is possible to use the results.

When analyzing efforts to enhance the use of evidence in designing such strategies, we chose to examine the use of scientific evidence in the process and the moment in which it was used ¹⁸18. Hanney SR, Gonzalez-Block MA, Buxton MJ, Kogan M. The utilisation of health research in policy-making: concepts, examples and methods of assessment. Health Res Policy Syst 2003; 1:2.^,1919. Lavis JN. Research, public policymaking, and knowledge-translation processes: Canadian efforts to build bridges. J Contin Educ Health Prof 2006; 26:37-45., its purpose ²⁰20. Amara N, Ouimet M, Landry R. New evidence on instrumental, conceptual, and symbolic utilization of university research in government agencies. Sci Commun 2004; 26:75-106.^,2121. Trostle J, Bronfman M, Langer A. How do researchers influence decision-makers? Case studies of Mexican policies. Health Policy Plan 1999; 14:103-14., the approaches ²²22. Lavis JN, Lomas J, Hamid M, Sewankambo NK. Assessing country-level efforts to link research to action. Bull World Health Organ 2006; 84:620-8., and the strategies used to inform policy-making with scientific evidence.

Ideas factor in the PMM (Brazil)

According to the interviewees, the scientific evidence from research results and other data from the CFM and Ministry of Health were used in the PMM to both inform and oppose the policy ²³23. 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: Núcleo de Estudos em Saúde Coletiva, Faculdade de Medicina, Universidade Federal de Minas Gerais; 2009.^,2424. Carvalho CL, Farah JM, Araújo JF, Wan der Maas L, Campos LAB. Construção do índice de escassez de profissionais de saúde para apoio à Política Nacional de Promoção da Segurança Assistencial em Saúde. Belo Horizonte: Núcleo de Estudos em Saúde Coletiva, Faculdade de Medicina, Universidade Federal de Minas Gerais; 2010.^,2525. Observatório de Recursos Humanos em Saúde/Estação de Trabalho do IMS/UERJ. Sistema de Indicadores das Graduações em Saúde - SIGRAS. http://www.obsnetims.org.br/sigras/home.php (acessado em 30/Dez/2016).
http://www.obsnetims.org.br/sigras/home.... ^,2626. Seixas PH, Corrêa A, Moraes J. Migramed - Migração Médica no Brasil: tendências e motivações. In: Pierantoni CR, Dal Poz MR, França T, organizadores. O trabalho em saúde: abordagens quantitativas e qualitativas. Rio de Janeiro: Centro de Estudos, Pesquisa e Desenvolvimento Tecnológico em Saúde Coletiva, Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro/ObservaRH; 2011. p. 133-50.^,2727. Scheffer M, Biancarelli A, Cassenote A. Demografia médica no Brasil. v. 2: dados gerais e descrições de desigualdades. São Paulo: Conselho Regional de Medicina do Estado de São Paulo/Conselho Federal de Medicina; 2013.. As for the moment in which the evidence was used, the policy-makers reported that the use of domestic scientific evidence stemmed from the identification of the problem and its causes, from the needs for adjustments to strategies chosen for implementation, and more recently from the assessment of the PMM. In addition, sources used to identify possible solutions included the international literature, systematic international reviews, and other studies of strategies used in different countries ¹⁵15. Chopra M, Munro S, Lavis JN, Vist G, Bennett S. Effects of policy options for human resources for health: an analysis of systematic reviews. Lancet 2008; 371:668-74.^,1616. World Health Organization. Transforming and scaling up health professionals' education and training: World Health Organization guidelines 2013. Geneva: World Health Organization; 2013.^,1717. World Health Organization. Increasing access to health workers in remote and rural areas through improved retention. Geneva: World Health Organization; 2010.. The interviewees also identified the exchange of experiences with policy-makers from other countries during meetings of the World Health Organization (WHO), on strategies used to correct the uneven distribution of physicians. According to one researcher, no other policy had generated as much investment as the PMM to assess such a program (BR_P2).

According to policy-makers and researchers, PMM spawned a debate between medical associations and the Ministry of Health. According to the policy-makers, the medical associations used research results to oppose the PMM during the policy design and initial implementation stages ²⁷27. Scheffer M, Biancarelli A, Cassenote A. Demografia médica no Brasil. v. 2: dados gerais e descrições de desigualdades. São Paulo: Conselho Regional de Medicina do Estado de São Paulo/Conselho Federal de Medicina; 2013.. They also used the argument that the lack of incentives for physicians to work in these underserved areas was the main problem, not the shortage of physicians (BR_P4).

According to researchers and policy-makers, one of the approaches that promoted the use of scientific evidence was the effort to collect evidence by users that turned to research to extract information and thus make decisions. In other words, such efforts are appropriate in situations in which the potential users have identified a knowledge gap and seek a timely solution ²²22. Lavis JN, Lomas J, Hamid M, Sewankambo NK. Assessing country-level efforts to link research to action. Bull World Health Organ 2006; 84:620-8.. According to the policy-makers, researchers, and some interest group actors, another approach involved efforts at exchange, which occurs when producers or providers of research develop significant partnerships with a group of users who help them identify and answer relevant questions ²²22. Lavis JN, Lomas J, Hamid M, Sewankambo NK. Assessing country-level efforts to link research to action. Bull World Health Organ 2006; 84:620-8.. The Secretariat of Labor Management and Health Education (SGTES) of the Brazilian Ministry of Health has a relationship with a set of researchers from the Network of Observatories on Human Resources in Health in Brazil (ObservaRH), who have produced a set of studies commissioned and/or financed by the Ministry of Health, and that served to inform the program’s policy-making (BR_P4).

According to policy-makers, a mechanism for streamlining the use of research results in the Ministry of Health was direct financing with the presentation of interim results by the researcher. According to the policy-maker, the traditional funding mechanism used by the Ministry of Health (call for projects) requires two to three years to produce results, plus the time for writing and publishing the article (BR_PM3).

Concerning the purpose for using the scientific evidence, the main discussion in the field focuses on three types of use of research: instrumental, conceptual, and symbolic ⁸8. Innvaer S, Vist G, Trommald M, Oxman A. Health policy-makers' perceptions of their use of evidence: a systematic review. J Health Serv Res Policy 2002; 7:239-44.^,2020. Amara N, Ouimet M, Landry R. New evidence on instrumental, conceptual, and symbolic utilization of university research in government agencies. Sci Commun 2004; 26:75-106.. In the specific case of the PMM, there is no consensus among the stakeholders concerning the purpose for the use of evidence generated by research, varying from conceptual use, which involves a more generic and indirect use of the evidence, instrumental use, with specific and direct application of the results, and symbolic use, in which the research is used to validate and support decisions that have already been made, for other reasons ²⁰20. Amara N, Ouimet M, Landry R. New evidence on instrumental, conceptual, and symbolic utilization of university research in government agencies. Sci Commun 2004; 26:75-106.^,2828. Haynes AS, Gillespie JA, Derrick GE, Hall WD, Redman S, Chapman S, et al. Galvanizers, guides, champions, and shields: the many ways that policymakers use public health researchers. Milbank Q 2011; 89:564-98..

Some interest group actors and researchers questioned whether the evidence had been used adequately in the case of the PMM. For example, one researcher mentioned that the report on medical demographics ²⁷27. Scheffer M, Biancarelli A, Cassenote A. Demografia médica no Brasil. v. 2: dados gerais e descrições de desigualdades. São Paulo: Conselho Regional de Medicina do Estado de São Paulo/Conselho Federal de Medicina; 2013. had been used both by medical associations contrary to the PMM, to contend that there was no shortage of physicians in Brazil, and by policy-makers, to support the claim that there was a shortage of physicians. Interviewees from the group of researchers and stakeholders in the PMM asked whether the abnormal and disproportional volume of investments in research, compared to other components of the health system, was really meant to validate the PMM (BR_P1).

Finally, two determinants were identified that facilitate the use of evidence, namely the acknowledgment of the importance of using evidence in policy-making by the stakeholders, including the policy-makers, and the characteristic of the policy-making process in Brazil, which includes forums for discussions.

The majority of the interviewees acknowledged the importance of: (1) use of research evidence in all phases of the policy process in Brazil and (2) an organizational culture for the use of such evidence. One of the policy-makers stated that evidence from both domestic and international research is used to shed light on policy debates, a position taken by the Office of the President, Office of the Chief of Staff, and the Ministry of Health (BR_PM3). However, some researchers interviewed in this study admitted that evidence is not the only factor that influences policy-making, and that it may not be the “priority” among competing factors. Meanwhile, evidence is used to enhance the response to a problem that was initially influenced by other factors such as political pressures and demands (BR_P2).

According to the policy-makers, there were various forums for discussion of the possible solutions to the problem of physician distribution in Brazil, such as the National Health Council (CNS). The discussions in these forums on the PMM lasted approximately four months, before the program’s implementation in July 2013 and during the process leading up to the Executive Order (BR_PM2).

According to the interest groups, these dialogues took place quickly and when the possible interventions were already being presented, rather than merely during the policy design. This stage involved technical discussion with divergent information among the actors. Based on data and studies, members of the government administration pointed to a lack of physicians in the target municipalities (counties), while the medical associations also drew on commissioned studies to contend that the problem was not the number of physicians but their distribution, and that the problem thus called for improving the career plan system for physicians (BR_IO1).

In a policy decision, even among specialists, there may be diverging opinions on the meaning, interpretation, and perception of sufficiency of evidence for making the decision, or even for its use to defend different policy solutions to a problem. In this scenario, some stakeholder groups, like specialists, can wield power and influence the type of evidence that will be used, as well as the purpose and moment of its use ²⁹29. Greyson DL, Cunningham C, Morgan S. Information behaviour of Canadian pharmaceutical policy makers. Health Info Libr J 2012; 29:16-27.. According to one researcher, the use of scientific evidence by renowned Brazilian institutes can lend a kind of power to policy-makers, a sort of power perhaps created by the “issue of scientificity”, based on the researcher’s impartiality. Thus, the empowerment of citizens and other actors in the use of scientific evidence to advocate for a strategy and participation in the policy debate can help reduce the incorrect use of such evidence (BR_P3).

Ideas factor in the bilateral agreements (Portugal)

Scientific evidence did not contribute to the policy decisions on the strategy for hiring foreign physicians in Portugal. According to the policy-makers, the policy decisions for this strategy drew on an exchange of experiences with policy-makers from other countries (PT_PM2).

Scientific evidence played a role in introducing the problem on the government agenda, helping identify the problem and thus raising the need to design a policy for the strategy through a descriptive study ³⁰30. Grupo de Missão. Plano estratégico para a formação nas áreas da saúde. Lisboa: Grupo de Missão; 2001. and a prospective quantitative study on the need for physicians ³¹31. Santana P, Couceiro L, Alves I, Nogueira H, Costa C, Santos R. Caracterização demográfica dos profissionais de saúde no serviço nacional de saúde português. v. V: sumário executivo. Lisboa: Secretaria-Geral, Ministério da Saúde; 2007.. These studies were commissioned directly to the researchers by the Ministry of Health ³¹31. Santana P, Couceiro L, Alves I, Nogueira H, Costa C, Santos R. Caracterização demográfica dos profissionais de saúde no serviço nacional de saúde português. v. V: sumário executivo. Lisboa: Secretaria-Geral, Ministério da Saúde; 2007. and Ministry of Education ³⁰30. Grupo de Missão. Plano estratégico para a formação nas áreas da saúde. Lisboa: Grupo de Missão; 2001.. Other types of evidence like technical reports with information taken from databases prepared by technical groups from the Ministry of Health were also used (PT_PM4).

The approach to promote the use of scientific evidence in shaping the agenda (inclusion of the physician distribution issue) was the effort to collect evidence by the user, the same mechanism used in Brazil. Direct financing was identified in Portugal as the way to streamline the process of using research results in the Ministry of Health (PT_ PM4).

The bilateral agreements in Portugal sparked a debate, and the medical associations were opposed to them, citing research results during the implementation phase ³²32. Santana P, Peixoto H, Loureiro A, Costa C, Nunes C, Duarte N. Estudo de evolução prospectiva de médicos no sistema nacional de saúde: relatório final. Coimbra: Ordem dos Médicos; 2013.. The Portuguese medical associations used the same argument as their Brazilian colleagues, namely that the lack of incentives for physicians to work in underserved areas was the main problem, and not a shortage of physicians (PT_EM1).

The majority of the interviewees acknowledged the potential for use of research in the initial phase of the policy decision-making process (shaping the policy agenda). In addition, some stakeholders questioned whether scientific evidence could really be used adequately, or only to support a decision already made (symbolic).

Thus, the low priority assigned by the main source of financial support (the national research funding agency) to research in health services or human resources for health ³³33. Dussault G. Plano nacional de saúde 2012-2016: roteiro de intervenção em recursos humanos em saúde (RHS). Lisboa: Direção-Geral da Saúde; 2014. and thus the limited number of studies in the area, besides the lack of recognition by the actors concerning the importance of using evidence in other phases of the policy, may have been reflected in the use of research centered on the identification of the problem for designing the bilateral agreements in Portugal.

The study presents some limitations that are inherent to the case study method, like the impossibility of extrapolating the findings to another context (external validity). To ensure the findings’ credibility (internal validity), the methodological steps were followed rigorously: a tested interview questionnaire and triangulation of data sources used different data collection procedures for analysis of the context ¹⁰10. Oliveira APC, Gabriel M, Dal Poz MR, Dussault G. Desafios para assegurar a disponibilidade e acessibilidade à assistência médica no Sistema Único de Saúde. Ciênc Saúde Coletiva 2017; 22:1165-80.^,1111. Oliveira APC, Dussault G, Craveiro I. Challenges and strategies to improve the availability and geographic accessibility of physicians in Portugal. Hum Resour Health 2017; 15:24.. Finally, the inferences were based on scientific evidence prior to the current study.

Final remarks

The factors most frequently identified in the PMM as influencing the policy process and competing with the ideas (scientific evidence) were the institutions (government structure and policy legacy), external factors (Presidential elections), and various stakeholders’ interests. In the bilateral agreements in Portugal, the interviewees reported that the process had been influenced predominantly by interests and institutions (centralization of the process), with a limited role for evidence in the problem’s inclusion on the policy agenda.

Contrary to the findings in the case study in Brazil, where evidence played an important role in the policy, in Portugal the scientific evidence produced by research was not identified as having contributed to the human resources policy. The study identified different determinants in the restriction of the role of evidence in the policy process for hiring foreign physicians in the bilateral agreements and the use of evidence in the policy process for the PMM.

On the one hand, the characteristic of the policy-making process in the country - the policy process in Portugal was concentrated in a few actors; and in the case of Brazil, the process involved a variety of actors, including the Ministry of Health, the Office of the Chief of Staff, and the Ministry of Education, and also forums for discussions inherent to the characteristic of the policy process in the country. On the other hand, the organizational culture for the use of evidence - in Brazil, evidence was included in the policy process with some instruments, especially the research agenda and with strategies like the ObservaRH. No institutional mechanisms were identified in Portugal that promoted the use of evidence in this human resources for health policy process.

In both countries, the study identified the need for interventions and policies that contemplate all areas of the health labor market and include measures that affect other sectors in addition to health. The potential reinforcement of the use of scientific evidence in policy-making could be achieved with investment in forums for discussion and platforms for interaction between researchers, policy-makers, and other users of research results and an increase in support for research through financing and mechanisms for the establishment of political priorities.

Future studies are important for evaluating the strategies implemented in these two countries, to analyze the drain of health professionals through emigration and the flow from the public to the private healthcare sector or to other sectors, besides dual employment, to produce a more accurate diagnosis of the distribution of physicians between levels of care, to explore the organizational culture for use of evidence by analyzing beliefs and attitudes, to analyze the work by knowledge-brokering organizations, using other policies, and to produce more studies on the factors that lead physicians to migrate or to work in underserved regions.

Acknowledgments

The authors wish to thank Prof. John N. Lavis for his valuable comments on the multiple case study method, the interviewees for their valuable time and information, and Pedro Leite Alves for his technical assistance. Thanks also to Brazilian National Research Council (PhD scholarship 01988/2012-7) and Rio de Janeiro State Research Foundation (E26/201359/2014) for the funding.

References

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