Abstract

Introduction

Health workforce shortage is one of the bottlenecks to universal access to health care ¹1. Campbell J. The route to effective coverage is through the health worker: there are no shortcuts. Lancet 2013; 381:725.. Factors such as the demographic and epidemiological transition and the implementation of new health care models affect the need for health workers, and less developed and peripheral regions are generally the most underserved in terms of the availability and quality of the health workforce ²2. Dal Poz MR. A crise da força de trabalho em saúde. Cad Saúde Pública 2013; 29:1924-26..

In fact, in addition to posing a problem for equity, workforce concentration leads to inefficiency in health systems ³3. Araújo E, Maeda A. How to recruit and retain health workers in rural and remote areas in developing countries: a guidance note. Washington DC: World Bank; 2013. (Health, Nutrition and Population Discussion Paper).. As for global distribution of physicians, despite an increase in the total number, the pattern is one of concentration in large cities and shortages in rural areas ⁴4. Attal-Toubert K, Vanderschelden M. La démographie médicale à l'horizon 2030: de nouvelles projections nationales et régionales détailllées. Dossiers Solidarité Santé 2009; (12):1-66..

Regulation of the health workforce has been a global challenge. The migratory movement of physicians, according to Rovere ⁵5. Rovere MR. El Programa Más Médicos: un análisis complementario desde la perspectiva de la salud internacional. Interface (Botucatu, Online) 2015; 19:635-6., tends to follow a “market-oriented” logic as opposed to a “policy-oriented” or “needs-oriented” logic. The medical profession’s interests are not impartial; on the contrary, the profession takes organized moves to maintain the undersupply through regulation of human resources and pressure on health systems in favor of liberal medical practice.

Brazil presents similar problems that date to before the Brazilian Unified National Health System (SUS), with a history of ineffective health workforce policies and planning, subordinated to private interests ⁶6. Carvalho M, Santos NR, Campos GWS. A construção do SUS e o planejamento da força de trabalho em saúde no Brasil: breve trajetória histórica. Saúde Debate 2013; 37:372-87..

Implementation of the SUS, with its guidelines of universality, comprehensiveness, and decentralization, demanded an increased supply of human resources, especially in primary health care, which faces major challenges for retention and qualification of physicians for adequate action by the family health teams ⁷7. Giovanella L, Mendonça MHM. Atenção primária à saúde. In: Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e sistema de saúde no Brasil. 2ª Ed. Rio de Janeiro: Editora Fiocruz; 2012. p. 494-545.. In addition, limited state regulation of the health care labor market, especially the market for physicians (a profession that maintains strong power for self-regulation), is another factor that hinders the attraction and retention of physicians in priority areas for the SUS ⁸8. Rodrigues PHA, Ney MS, Paiva CHA, Souza LMBM. Regulação do trabalho médico no Brasil: impactos na Estratégia Saúde da Família. Physis (Rio J.) 2013; 23:1147-66..

Brazil suffers from sharp disparities in the distribution of physicians, concentrated in cities to the detriment of the country’s less developed regions ⁹9. Morais I, Alkmin D, Lopes J, Santos M, Leonel M, Santo R, et al. Jornais Folha de São Paulo e Correio Braziliense: o que dizem sobre o Programa Mais Médicos? Rev Esc Enferm USP 2014; 48:107-15.. In 2013, in a context of serious political and social tensions, the More Doctors Program (PMM, for its acrononym in Portuguese) ¹⁰10. Brasil. Lei nº 12.871, de 22 de outubro de 2013. Institui o Programa Mais Médicos, altera a lei no 8.745, de 9 de dezembro de 1993, e nº 6.932, de 7 de julho de 1981, e dá outras providências. Diário Oficial da União 2013; 23 out. was established during a “window of opportunities” in this scenario ¹¹11. Couto MP. O Programa Mais Médicos: a formulação de uma nova política pública de saúde no Brasil [Dissertação de Mestrado]. Curitiba: Universidade Federal do Paraná; 2015.. The PMM was structured along three strategic lines, involving changes in medical training, improvement of infrastructure for the basic health units (UBS in the Portuguese acronym), and emergency provision of physicians ¹⁰10. Brasil. Lei nº 12.871, de 22 de outubro de 2013. Institui o Programa Mais Médicos, altera a lei no 8.745, de 9 de dezembro de 1993, e nº 6.932, de 7 de julho de 1981, e dá outras providências. Diário Oficial da União 2013; 23 out..

Three years since the establishment of the PMM, with the recruitment of more than 18 thousand physicians from 2013 to 2016, there has been an improvement in the shortage of physicians in basic care, especially in more vulnerable areas ¹²12. Girardi SN, Stralen ACS, Cella JN, Maas LWD, Carvalho CL, Faria EO. Impacto do Programa Mais Médicos na redução da escassez de médicos em atenção primária à saúde. Ciênc Saúde Coletiva 2016; 21:2675-84.. The Program’s capillarity reached nearly the entire territory of Brazil, predominantly with Cuban physicians, who accounted for 79% of the participants as of 2014 ¹³13. Secretaria de Gestão e Educação do Trabalho em Saúde, Ministério da Saúde. Programa Mais Médicos - dois anos: mais saúde para os brasileiros. Brasília: Ministério da Saúde; 2015..

Implementation of the PMM met strong resistance from the medical profession. The controversy over participation by foreign physicians, especially Cubans, involved not only issues related to the work market and training, but questions as to the width and breadth of the practices by these professionals ⁹9. Morais I, Alkmin D, Lopes J, Santos M, Leonel M, Santo R, et al. Jornais Folha de São Paulo e Correio Braziliense: o que dizem sobre o Programa Mais Médicos? Rev Esc Enferm USP 2014; 48:107-15.. What was questioned was the quality of Cuban medical training to deal with the complexity of actions required for work in basic care in the SUS.

This article aims to analyze the comprehensiveness of practices by Cuban physicians in the context of the PMM. Comprehensiveness is a guideline of the SUS ¹⁴14. Mattos RA. Os sentidos da integralidade: algumas reflexões acerca de valores que merecem ser defendidos. In: Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade na atenção e no cuidado à saúde. 8ª Ed. Rio de Janeiro: Centro de Estudos e Pesquisa em Saúde Pública, Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro/Abrasco; 2009. p. 43-68.. It is determined both at the level of health work and in the sphere of policies capable of intervening in the determinants of the health-disease-care process to guarantee satisfactory wellbeing for the population ¹⁴14. Mattos RA. Os sentidos da integralidade: algumas reflexões acerca de valores que merecem ser defendidos. In: Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade na atenção e no cuidado à saúde. 8ª Ed. Rio de Janeiro: Centro de Estudos e Pesquisa em Saúde Pública, Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro/Abrasco; 2009. p. 43-68.. The comprehensiveness of practices in primary health care involves a biopsychosocial approach to care for individuals and families, actions in the territory, and an expanded scope with case-resolution capacity ¹⁴14. Mattos RA. Os sentidos da integralidade: algumas reflexões acerca de valores que merecem ser defendidos. In: Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade na atenção e no cuidado à saúde. 8ª Ed. Rio de Janeiro: Centro de Estudos e Pesquisa em Saúde Pública, Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro/Abrasco; 2009. p. 43-68.^,1515. Almeida PF, Giovanella L, Nunan BA. Atenção integral à saúde - indicadores para avaliação. Rio de Janeiro: Ministério da Saúde; 2011.^,1616. Silva Junior AG, Alves MGM, Costa MGL, Lima RHP. Regionalização, integralidade e produção do cuidado no contexto da Estratégia Saúde da Família: pontos para o debate. In: Almeida PF, Santos AM, Souza MKB, organizadores. Atenção primária à saúde na coordenação do cuidado em Regiões de Saúde. Salvador: Edufba; 2015. p. 65-88.. This study seeks to analyze whether, beyond decreasing the shortage of physicians and disparities in their distribution in Brazil, the work by physicians in the PMM is consistent with comprehensive practice.

Methodology

The comprehensiveness of practices by Cuban physicians in the PMM was analyzed in two dimensions. The dimension of the community-oriented biopsychosocial approach to care consists of elements that expand the objectives of care in primary health care beyond the biomedical aspects to involve psychological and social features, besides focusing further on work in the community ¹⁴14. Mattos RA. Os sentidos da integralidade: algumas reflexões acerca de valores que merecem ser defendidos. In: Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade na atenção e no cuidado à saúde. 8ª Ed. Rio de Janeiro: Centro de Estudos e Pesquisa em Saúde Pública, Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro/Abrasco; 2009. p. 43-68.^,1515. Almeida PF, Giovanella L, Nunan BA. Atenção integral à saúde - indicadores para avaliação. Rio de Janeiro: Ministério da Saúde; 2011.. It includes components that deal with a view to the territory ¹⁶16. Silva Junior AG, Alves MGM, Costa MGL, Lima RHP. Regionalização, integralidade e produção do cuidado no contexto da Estratégia Saúde da Família: pontos para o debate. In: Almeida PF, Santos AM, Souza MKB, organizadores. Atenção primária à saúde na coordenação do cuidado em Regiões de Saúde. Salvador: Edufba; 2015. p. 65-88., the centrality of subjects and their autonomy ¹⁴14. Mattos RA. Os sentidos da integralidade: algumas reflexões acerca de valores que merecem ser defendidos. In: Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade na atenção e no cuidado à saúde. 8ª Ed. Rio de Janeiro: Centro de Estudos e Pesquisa em Saúde Pública, Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro/Abrasco; 2009. p. 43-68.^,1616. Silva Junior AG, Alves MGM, Costa MGL, Lima RHP. Regionalização, integralidade e produção do cuidado no contexto da Estratégia Saúde da Família: pontos para o debate. In: Almeida PF, Santos AM, Souza MKB, organizadores. Atenção primária à saúde na coordenação do cuidado em Regiões de Saúde. Salvador: Edufba; 2015. p. 65-88.^,1717. Silva Junior AG, Mascarenhas MTM. Avaliação da atenção básica em saúde sob a ótica da integralidade: aspectos conceituais e metodológicos. In: Pinheiro R, Mattos RA, organizadores. Cuidado: as fronteiras da integralidade. Rio de Janeiro: Abrasco/São Paulo: Editora Hucitec; 2004. p. 241-57., inter-sector collaboration ¹⁵15. Almeida PF, Giovanella L, Nunan BA. Atenção integral à saúde - indicadores para avaliação. Rio de Janeiro: Ministério da Saúde; 2011., valorization of social determinants ¹⁵15. Almeida PF, Giovanella L, Nunan BA. Atenção integral à saúde - indicadores para avaliação. Rio de Janeiro: Ministério da Saúde; 2011., and active collective participation in building health projects ¹⁴14. Mattos RA. Os sentidos da integralidade: algumas reflexões acerca de valores que merecem ser defendidos. In: Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade na atenção e no cuidado à saúde. 8ª Ed. Rio de Janeiro: Centro de Estudos e Pesquisa em Saúde Pública, Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro/Abrasco; 2009. p. 43-68.^,1616. Silva Junior AG, Alves MGM, Costa MGL, Lima RHP. Regionalização, integralidade e produção do cuidado no contexto da Estratégia Saúde da Família: pontos para o debate. In: Almeida PF, Santos AM, Souza MKB, organizadores. Atenção primária à saúde na coordenação do cuidado em Regiões de Saúde. Salvador: Edufba; 2015. p. 65-88.^,1818. Pinheiro R, Silva Junior AG. Práticas avaliativas e as mediações com a integralidade na saúde: uma proposta para estudos de processos avaliativos na atenção básica. In: Pinheiro R, Silva Junior AG, Mattos RA, organizadores. Atenção básica e integralidade: contribuições para estudos de práticas avaliativas em saúde. Rio de Janeiro: Centro de Estudos e Pesquisa em Saúde Pública, Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro/Abrasco; 2011. p. 17-41..

The dimension of the range of actions in health promotion, prevention, and health care includes aspects in the physicians’ activities that point to comprehensive care with case-resolution capacity, such as: a wide portfolio of services for promotion, prevention, and care ¹⁹19. Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviço e tecnologia. Brasília: Organização das Nações Unidas para a Educação, a Ciência e a Cultura/Ministério da Saúde; 2002., attention to both the spontaneous and scheduled demand ¹⁴14. Mattos RA. Os sentidos da integralidade: algumas reflexões acerca de valores que merecem ser defendidos. In: Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade na atenção e no cuidado à saúde. 8ª Ed. Rio de Janeiro: Centro de Estudos e Pesquisa em Saúde Pública, Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro/Abrasco; 2009. p. 43-68.^,1515. Almeida PF, Giovanella L, Nunan BA. Atenção integral à saúde - indicadores para avaliação. Rio de Janeiro: Ministério da Saúde; 2011., integration with other health services, interdisciplinarity ¹⁶16. Silva Junior AG, Alves MGM, Costa MGL, Lima RHP. Regionalização, integralidade e produção do cuidado no contexto da Estratégia Saúde da Família: pontos para o debate. In: Almeida PF, Santos AM, Souza MKB, organizadores. Atenção primária à saúde na coordenação do cuidado em Regiões de Saúde. Salvador: Edufba; 2015. p. 65-88.^,1919. Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviço e tecnologia. Brasília: Organização das Nações Unidas para a Educação, a Ciência e a Cultura/Ministério da Saúde; 2002., planning of interventions ¹⁵15. Almeida PF, Giovanella L, Nunan BA. Atenção integral à saúde - indicadores para avaliação. Rio de Janeiro: Ministério da Saúde; 2011., and use of clinical protocols ¹⁴14. Mattos RA. Os sentidos da integralidade: algumas reflexões acerca de valores que merecem ser defendidos. In: Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade na atenção e no cuidado à saúde. 8ª Ed. Rio de Janeiro: Centro de Estudos e Pesquisa em Saúde Pública, Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro/Abrasco; 2009. p. 43-68.^,1616. Silva Junior AG, Alves MGM, Costa MGL, Lima RHP. Regionalização, integralidade e produção do cuidado no contexto da Estratégia Saúde da Família: pontos para o debate. In: Almeida PF, Santos AM, Souza MKB, organizadores. Atenção primária à saúde na coordenação do cuidado em Regiões de Saúde. Salvador: Edufba; 2015. p. 65-88.^,1717. Silva Junior AG, Mascarenhas MTM. Avaliação da atenção básica em saúde sob a ótica da integralidade: aspectos conceituais e metodológicos. In: Pinheiro R, Mattos RA, organizadores. Cuidado: as fronteiras da integralidade. Rio de Janeiro: Abrasco/São Paulo: Editora Hucitec; 2004. p. 241-57.. Box 1 shows the matrix developed by the authors, based on a literature review ¹⁴14. Mattos RA. Os sentidos da integralidade: algumas reflexões acerca de valores que merecem ser defendidos. In: Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade na atenção e no cuidado à saúde. 8ª Ed. Rio de Janeiro: Centro de Estudos e Pesquisa em Saúde Pública, Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro/Abrasco; 2009. p. 43-68.^,1515. Almeida PF, Giovanella L, Nunan BA. Atenção integral à saúde - indicadores para avaliação. Rio de Janeiro: Ministério da Saúde; 2011.^,1616. Silva Junior AG, Alves MGM, Costa MGL, Lima RHP. Regionalização, integralidade e produção do cuidado no contexto da Estratégia Saúde da Família: pontos para o debate. In: Almeida PF, Santos AM, Souza MKB, organizadores. Atenção primária à saúde na coordenação do cuidado em Regiões de Saúde. Salvador: Edufba; 2015. p. 65-88.^,1717. Silva Junior AG, Mascarenhas MTM. Avaliação da atenção básica em saúde sob a ótica da integralidade: aspectos conceituais e metodológicos. In: Pinheiro R, Mattos RA, organizadores. Cuidado: as fronteiras da integralidade. Rio de Janeiro: Abrasco/São Paulo: Editora Hucitec; 2004. p. 241-57.^,1818. Pinheiro R, Silva Junior AG. Práticas avaliativas e as mediações com a integralidade na saúde: uma proposta para estudos de processos avaliativos na atenção básica. In: Pinheiro R, Silva Junior AG, Mattos RA, organizadores. Atenção básica e integralidade: contribuições para estudos de práticas avaliativas em saúde. Rio de Janeiro: Centro de Estudos e Pesquisa em Saúde Pública, Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro/Abrasco; 2011. p. 17-41.^,1919. Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviço e tecnologia. Brasília: Organização das Nações Unidas para a Educação, a Ciência e a Cultura/Ministério da Saúde; 2002. and used to analyze the comprehensiveness of practices with their dimensions, components, and categories.

A qualitative study was performed in the city of Rio de Janeiro, Brazil, which received 165 physicians from the PMM (148 of whom were Cubans) from October 2013 to September 2015 (Departamento de Informática do SUS. Cadastro Nacional dos Estabelecimentos de Saúde. http://cnes.datasus.gov.br, accessed on 20/Oct/2015). The study selected the Territorial Planning Area (AP 3.1) with the most family health teams and UBS with physicians from the PMM. In June 2016, there were 30 physicians from the PMM working in 16 UBS in this territory. Field data were produced using interviews with physicians from the PMM and a focus group with the supervisors of the selected territory, from June to August 2016. The study visited 14 UBS and interviewed 24 physicians (M), whose profile is shown in Table 1. There were 6 refusals to participate in the study.

The work by the supervisors of the PMM, based on technical and pedagogical follow-up, aims to qualify medical practice ¹⁰10. Brasil. Lei nº 12.871, de 22 de outubro de 2013. Institui o Programa Mais Médicos, altera a lei no 8.745, de 9 de dezembro de 1993, e nº 6.932, de 7 de julho de 1981, e dá outras providências. Diário Oficial da União 2013; 23 out., influencing practices by participating physicians. The supervisors’ perspective helped identify changes in practices over time, besides either producing a counterpoint or lending validity to the physicians’ perceptions. Of the total of six supervisors (S) in the selected territory, four participated in the focus group. The focus group technique allows extracting different perceptions from social groups affected collectively by specific situations, complementing individual approaches, triangulating views, and obtaining more information about the reality at hand ²⁰20. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14ª Ed. São Paulo: Editora Hucitec; 2014..

The script for the interviews was based on the analytical matrix (Box 1), which also guided presentation of the results. The focus group included a moderator and a secretary and was guided by triggering questions.

The interviews and focus group were submitted to thematic analysis, consisting of the following phases ²⁰20. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14ª Ed. São Paulo: Editora Hucitec; 2014.: ordering the material according to the analytical categories; horizontal and exhaustive reading for empirical categorization; cross-sectional reading based on the analytical categories; and clarification of the internal logic of the context in which medical practice takes place, in relation to comprehensiveness.

The study was approved by the institutional review boards of the Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation and the Rio de Janeiro Municipal Health Department, under case reviews 1.526.773 and 1.558.250.

Results

Community-oriented biopsychosocial approach to care

Territorial dynamics

Territorial dynamics are valued in the practices by the Cuban physicians in the PMM. The physicians identified the risks affecting the population covered by the program through the team’s planning routine, including analysis of health indicators and priority-setting for scheduling appointments, and especially the health surveillance exercised by community health agents (ACS, for its acrononym in Portuguese), who had more detailed information on the territory. However, few of these physicians (3) used a map to locate environmental, biological, and social risks, since the abundance of risk conditions and their uniform distribution across the territory hindered drawing a map.

The Cuban doctors showed extensive knowledge of the demographic and epidemiological profile of the population covered in the territory. Some reported the precise number of families and groups they accompanied, emphasizing the large population contingent. The population surplus led to heavy pressure for care from the team and was intensified by the territory’s extreme vulnerability and the severity of the diseases, due to the difficulty in access to medical care before the arrival of the PMM (Box 2, M17).

All 24 physicians identified flagrant social inequalities in the territory, expressed in important social determinants such as poor hygienic conditions in the homes, poverty, unemployment, and work informality. Violence, closely associated with the drug traffic, was a sensitive point frequently cited by these doctors.

The epidemiological profile identified by the Cuban physicians was largely related to the prevalence of chronic diseases and the adverse living conditions in the territory. The high rates of sexually transmissible diseases, especially syphilis, as well as tuberculosis, were associated with severe social vulnerability. High tuberculosis incidence was emphasized in the interviews, since the disease is rare in Cuba, representing a novelty for them in management in primary health care (Box 2, M16).

All the interviewees (24) reported a wide range of measures to deal with the risks they identified. They acted case by case, through patient consultations and home visits or broader proposals for the entire population, mainly using health education groups, suggesting an approach to population risks beyond the more individual patient-centered pattern of medical work (Box 2, M6 and S1). All such actions relied on linkage with the professionals from the Nucleus to Support Family Health (NASF) as well as partnerships with community leaders.

Centrality of subjects and their autonomy

All the interviewees reported adopting attitudes and techniques to approach individuals as the center of care. Most of the physicians (18) cited the need to understand the user’s family and social context. Another important tool in the person-centered approach was the valorization of attentive listening. Some physicians (8) cited exploring such subjective aspects as knowledge of the illness, the way sick individuals are perceived by others, and feelings, expectations, and reactions to health problems.

They also highlighted the unique manifestations of diseases in each person and the data from the clinical examination that led them to reflect on personal factors to understand the patient’s condition (Box 2, M4). There were also answers (8) suggesting rejection of medicalization and the “complaint-approach” model of medical practice, pointing to forms of humanization of care as a counterpoint. Others (7) underscored the user-physician bond and solidarity (Box 2, M12). The bond was emphasized in the relationship of trust between the patient and physician, fostered by continuous follow-up over time, promoting the assimilation of idiosyncrasies and vicissitudes.

Another strategy in the person-centered approach was ollaboration with other professionals from the family health team and especially from the NASF. A few interviewees (3) reported difficulty in focusing more time on individual patients due to the overload of consultations.

Meanwhile, the supervisors expressed ambiguity towards application of the person-centered approach. Based on their experience with specific training in the person-centered clinical method, the supervisors argued that the Cuban physicians lacked the training to explore the method’s steps and that they performed the steps intuitively, although the specialization course in family health provided the conceptual fundamentals. They felt that the Cuban doctors were concerned with the care, had ample knowledge of the users under their care, and worked to create a bond and understand the patients’ own experiences with their illness (Box 2, S2). Still, the supervisors argued that given the lack of specific training with the method, the physicians would experience difficulties managing the person-centered approach within the short time available for each individual consultation. However, two supervisors said that the more intuitive approach did not jeopardize the centrality of the person in the Cuban physicians’ approach.

One of the steps that characterizes the individual’s centrality and autonomy is negotiation of the case management with the user. The great majority (22) of the physicians stated that their conduct was carefully explained to the patient in order for him or her to understand the clinical decision, as a form of participation and point of departure to reach a consensus and increase treatment adherence. However, some contradictions were identified in the comments, with an emphasis on the need for compliance with prescriptions and the predominance of medical knowledge as a guide for the therapeutic and diagnostic process (Box 2, M3).

Inter-sector collaboration

Among the 19 physicians that cited collaboration with other sectors, all of them mentioned activities with schools and daycare centers, mainly through the School Health Program (Box 2, M1). Some mentioned activities with churches, sports, and the neighborhood association (Box 2, M7). Four physicians mentioned collaboration with the social workers in the NASF, conducted in a few cases (Box 2, M16). Six had made contact with the Reference Center for Social Assistance.

Pressure from the overload of consultations was cited as a limiting factor for collaboration, and the physicians also emphasized difficulties due to the lack of social infrastructure in the territory. The supervisors stated that inter-sector collaboration is a challenge for any physician practicing in primary health care. When such activities occurred, they were undertaken by the UBS management or at the initiative of the community health agent (Box 2, S3).

Importance of social determinants

The importance of social determinants of health was acknowledged by the Cuban doctors in the PMM. All the physicians (24) said they were familiar with the Brazilian Income Transfer Program (Programa Bolsa Família; conditional cash transfer) program and participated in the follow-up of the enrolled users. A few (3) reported limitations for expanding their participation in the follow-up of Brazilian Income Transfer Program users, citing the stigma associated with this social benefit and (again) the overload with patient consultations.

They reported different experiences in relation to social vulnerability. The most frequently cited conduct was involvement by the team, NASF, and/or social assistance. Some doctors also conducted more home visits and consultations for the more vulnerable cases, as also reported in the focus group (Box 2, S1).

Another form of work was keeping the team available to receive patients, both with their immediate demands and on preventive issues. The physicians mentioned the priority of scheduling, coordination of more systematic care, support for the role of community health agents in surveillance, and material assistance (donation of food, diapers, cleaning products, etc.) in cases involving greater social vulnerability. Some (3) reported that beyond their own work, more government funding was needed (Box 2, M5).

The focus group emphasized that the Cuban doctors were more sensitive to issues of social risk, but that they showed weaknesses in differentiating some cases of social vulnerability, for example, a more systematic approach to domestic violence.

Active participation in community groups building health projects

The majority of the Cuban physicians (22) participated in developing the community diagnosis and considered the demands and the support of local leaders when analyzing the territory’s problems and potentialities (Box 2, M8). The physicians worked with both formal and informal community leaders (Box 2, M6). Still, the community diagnosis was based on the study of the electronic patient file, with the main focus on diseases (Box 2, M14).

Some Cuban doctors cited the annual accountability seminar required by the municipal administration as the time for conducing the community diagnosis. In addition to the health councils that existed in some UBS, regular meetings were held with users for accountability and clarifications. Most of the doctors (21) did not participate in these meetings or in the health councils.

Range of activities in health promotion, prevention, and patient care

Extensive portfolio of services in promotion, prevention, and care

Among the practices in health promotion and prevention of individual health problems, such as counseling on life habits, all the interviewees reported orienting patients on healthy eating and smoking cessation and recommended harm reduction measures for alcohol and drug users, with the greatest difficulties in the latter cases (Box 3, M20). Prejudice and social stigma hindered the approach to (and identification of) alcohol abusers and especially illicit drug users.

There was some variation among the doctors in relation to performing invasive procedures: according to their reports, 18 removed earwax, 12 inserted intrauterine devices, eight performed sutures, and six removed ingrown toenails (Box 3, M18). Few said they lacked training, and those that did not perform such procedures voiced various justifications: lack of material and adequate spaces, lack of demand for the service at the UBS, insufficient time, and avoiding the creation of a demand for treating wounds from armed confrontations. The supervisors realized that not all these physicians performed invasive procedures, despite requirements by the municipal administration (Box 3, S4), due to training and pressure from patient consultations.

Attention to spontaneous and scheduled demand

All the interviewees (24) reported treating the spontaneous demand. There were various ways of dealing with the spontaneous demand, highlighting “advanced access”, which aimed to provide as many places as possible for medical consultations on the same day, thus reducing the waiting time (Box 3, M5). According to the supervisors, welcoming the spontaneous demand was incorporated without the physicians having to limit it or refuse to see patients. They reiterated the practice of “advanced access”, a contribution by the supervisor that proved opportune for the physicians’ reality.

All the Cuban physicians (24) reported accompanying priority groups, organizing follow-up, and attempting to adhere to protocol for each condition, but with flexibility. This care was shared with the nurses from the family health team (Box 3, M19, M21).

The quotes by the focus group agreed with the interviews but highlighted limitations in the approach to mental health cases. Supervisors mentioned a disadvantage in the specialized training of some professionals from the PMM in managing psychiatric conditions in primary health care, in addition to the language barrier.

Integration with other health services

Half of the Cuban physicians (12) only had contact with professionals in secondary or tertiary care through the referral guides. The other half communicated with specialists, but infrequently. Two underscored the importance of structuring and integrating the health network to improve relations with other levels of care (Box 3, M3). The interviewees voiced their fear of contacting Brazilian doctors in the health care network, due to heavy rejection of the PMM by the Brazilian medical profession, especially in the initial stage (Box 3, M21).

Even with the referral guide, interprofessional communication was not rated positively, since only seven Cuban doctors said they received counter-referrals regularly. The focus group also identified difficulties with direct communication in the municipal health system.

Interdisciplinarity

The Cuban doctors’ integration in the family health team was emphasized by the doctors themselves and by the focus group. Most of the Cuban physicians (18) highlighted the technical preparedness and capacity of the Brazilian nurses (“they’re almost doctors”, said some of the interviewees), as important partners for shared follow-up of users in teams with a surplus population to cover.

Some Cuban doctors (2) expressed difficulties with the turnover of nurses. According to one interviewee, there were some clashes with the nursing staff at the beginning of the PMM, because the nurses were not used to the range of activities by the PMM group in primary health care. The fact that nurses in Brazil perform consultations was new to the Cuban doctors and led to a more egalitarian relationship with greater dialogue (Box 3, M8).

The Cuban doctors highlighted the importance of the community health agents and the fact that their work expanded the possibilities for care. They mentioned the NASF at various moments in the interviews, especially the support in mental health and social assistance (Box 3, M17). The focus group reported that, with few exceptions, the Cuba physicians enjoyed good relations with all the members of the Family Health Strategy (ESF, in the Portuguese acronym), collaborating in patient care and case discussions.

Planning of interventions and use of clinical protocols

The Cuban doctors reported using the indicators provided by the electronic patient chart. The majority (20) planned activities based on the problems identified, such as active search and campaigns (Box 3, M21). Two doctors emphasized that the main focus of care was the quality of patient follow-up. The focus group also pointed to the use of performance indicators from the electronic patient chart for organizing work by the family health team, however, based on a notion of primary health care limited to health programs, with little emphasis as a device for discussing the process of care.

The great majority of the physicians (23) said they were familiar with the manuals produced by the Municipal Health Department for health care practices and patient flows in primary health care. The majority used the municipal or national protocols, emphasizing the importance of respecting the country’s guidelines. Few physicians (5) reported also using foreign references such as Cuban guidelines, guidelines of American medical societies, or others in the Spanish language.

The interviewees stated not having experienced difficulties in adapting to the Brazilian protocols. “The medicine is the same” was a common remark. The difference in relation to Cuba related to care for users with tuberculosis (since tuberculosis patients in Cuba are referred to specialists), maternal and child care, which is more rigorous in Cuba, and flowcharts, which are rarely used in Cuban practice (Box 3, M23). The focus group voiced a different position in relation to adequate use of clinical protocols and evidence-based medicine by the Cuban physicians. According to the supervisors, some of the Cuban doctors based their practice on empiricism, with resistance to reliance on scientific evidence (Box 3, S1).

The results indicate that the practices by Cuban physicians in the PMM displayed full or partial presence in all the components used to analyze comprehensiveness of practices. The dimension of actions in promotion, prevention, and care was somewhat stronger than the dimension of the community-orientated biopsychosocial approach to care, although strengths and weaknesses were found in both dimensions. However, the weaknesses in the list of activities related mainly to limitations that are outside the scope of the physicians’ work (for example, violence in the territory). Box 4 summarizes the main strengths and weaknesses in achieving comprehensiveness based on the assessment of the physicians interviewed and the supervisors’ viewpoints.

Discussion

The PMM raised questions as to its potential for offering quality health care to the population ²2. Dal Poz MR. A crise da força de trabalho em saúde. Cad Saúde Pública 2013; 29:1924-26.. Nevertheless, in relation to comprehensiveness, the study indicated good practices.

Strong territorial integration and community interaction are consistent with findings from other studies on practices in the PMM ²¹21. Comes Y, Trindade J, Pessoa VM, Barreto ICHC, Shimizu HE, Dewes D, et al. A implementação do Programa Mais Médicos e a integralidade nas práticas da Estratégia Saúde da Família. Ciênc Saúde Coletiva 2016; 21:2727-36.^,2222. Pereira LL, Silva HP, Santos LMP. Projeto Mais Médicos para o Brasil: Estudo de caso em comunidades quilombolas. Rev ABPN 2015; 7:28-51.^,2323. Pereira LL, Pacheco L. O desafio do Programa Mais Médicos para o provimento e a garantia da atenção integral à saúde em áreas rurais na região amazônica. Interface (Botucatu, Online) 2017; 21:1181-92.. Cuban medical training, targeted to the provision of community-oriented services ²⁴24. Keck CW, Reed GA. The curious case of Cuba. Am J Public Health 2012; 102:13-20., may have been a facilitating factor. More precise activities in territorialization could empower the action in settings of social reproduction of health-disease processes in areas covered by the family health teams ⁷7. Giovanella L, Mendonça MHM. Atenção primária à saúde. In: Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e sistema de saúde no Brasil. 2ª Ed. Rio de Janeiro: Editora Fiocruz; 2012. p. 494-545..

Although not highly systematized, the six steps to the person-centered approach ²⁵25. Lopes JMC. Consulta e abordagem centrada na pessoa. In: Gusso G, Lopes JMC, organizadores. Tratado de medicina de família e comunidade: princípios, formação e prática. Porto Alegre: Editora Artmed; 2012. p. 113-23. were present in practices by physicians in the PMM. Other studies have also identified the presence of elements of the person’s centrality and autonomy in the work by physicians in the PMM ²¹21. Comes Y, Trindade J, Pessoa VM, Barreto ICHC, Shimizu HE, Dewes D, et al. A implementação do Programa Mais Médicos e a integralidade nas práticas da Estratégia Saúde da Família. Ciênc Saúde Coletiva 2016; 21:2727-36.^,2323. Pereira LL, Pacheco L. O desafio do Programa Mais Médicos para o provimento e a garantia da atenção integral à saúde em áreas rurais na região amazônica. Interface (Botucatu, Online) 2017; 21:1181-92.^,2626. Organização Mundial da Saúde, Organização Pan-Americana da Saúde. Programa Mais Médicos no Município do Rio de Janeiro: mais acesso, equidade e resolutividade na APS. Brasília: Organização Pan-Americana da Saúde; 2016. (Série Estudos de Caso Sobre o Programa Mais Médicos, 2).. The assessments by the supervisors on this point appear to identify a certain tension and the defense of a Brazilian concept of family and community medicine, with limited openness to practices from other experiences. The person-centered approach and clinical method and the skills-based curriculum elaborated by the Brazilian Society of Family and Community Medicine are considered essential attributes in various fields of the specialty ²⁷27. Lermen Junior N. Currículo baseado em competências para Medicina de Família e Comunidade. http://www.rededepesquisaaps.org.br/wp-content/uploads/2015/04/Curriculo-Baseado-em-Competencias.pdf (acessado em 23/Out/2017).
http://www.rededepesquisaaps.org.br/wp-c... , which may explain the emphasis on more rigorous systematization of the method, based on the training model in Brazil.

The results indicate that inter-sector collaboration is facilitated when there are devices in place, like the School Health Program or to a lesser degree the Reference Center for Social Assistance. Still, problems identified in the communities appear to receive little or no attention through linkage at the local level alone. Giovanella et al. ²⁸28. Giovanella L, Mendonça MHM, Almeida PF, Escorel S, Senna MCM, Fausto MCR, et al. Saúde da família: limites e possibilidades para uma abordagem integral de atenção primária à saúde no Brasil. Ciênc Saúde Coletiva 2009; 14:783-94. point to a lack of inter-sector policies in management, stating that when actions are taken by the municipal executive, they strengthen the Family Health teams’ community activities in the territories.

Other studies have shown that professionals from the PMM value social determinants in their practices ²²22. Pereira LL, Silva HP, Santos LMP. Projeto Mais Médicos para o Brasil: Estudo de caso em comunidades quilombolas. Rev ABPN 2015; 7:28-51.^,2626. Organização Mundial da Saúde, Organização Pan-Americana da Saúde. Programa Mais Médicos no Município do Rio de Janeiro: mais acesso, equidade e resolutividade na APS. Brasília: Organização Pan-Americana da Saúde; 2016. (Série Estudos de Caso Sobre o Programa Mais Médicos, 2).. This aspect relates to comprehensiveness to the extent that it demonstrates capacity for expanded action beyond clinical care and suggests care with a focus on the sources of social reproduction of diseases ¹⁷17. Silva Junior AG, Mascarenhas MTM. Avaliação da atenção básica em saúde sob a ótica da integralidade: aspectos conceituais e metodológicos. In: Pinheiro R, Mattos RA, organizadores. Cuidado: as fronteiras da integralidade. Rio de Janeiro: Abrasco/São Paulo: Editora Hucitec; 2004. p. 241-57..

The physicians from the PMM interviewed here showed the capacity to identify leaders and establish important partnerships in the community, but low participation in local health councils. In Brazil, other authors have also pointed to health professionals’ difficulties in mobilizing and encouraging the populations to promote joint interventions. They have also emphasized the need to promote quality representation and expand the impacts of social control in health in policy decisions ¹⁹19. Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviço e tecnologia. Brasília: Organização das Nações Unidas para a Educação, a Ciência e a Cultura/Ministério da Saúde; 2002.^,2929. Escorel S, Moreira MR. Participação social. In: Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e sistema de saúde no Brasil. 2ª Ed. Rio de Janeiro: Editora Fiocruz; 2012. p. 853-84..

The dimension of the actions in health promotion, prevention, and care was achieved more fully by the Cuban physicians in the target categories. Girardi et al. ³⁰30. Girardi SN, Carvalho CL, Pierantoni CR, Costa JO, Stralen ACS, Lauar TV, et al. Avaliação do escopo de prática de médicos participantes do Programa Mais Médicos e fatores associados. Ciênc Saúde Coletiva 2016; 21:2737-46. found similar results with a diversified scope of actions, while identifying such limitations as lack of training, limited demand by users, and especially inadequate infrastructure in the UBS.

The difficulty in dealing with alcohol and drug users can be discussed from the perspective of the territory’s characteristics. A case study by World Helath Organization/Pan American Health Organization ²⁶26. Organização Mundial da Saúde, Organização Pan-Americana da Saúde. Programa Mais Médicos no Município do Rio de Janeiro: mais acesso, equidade e resolutividade na APS. Brasília: Organização Pan-Americana da Saúde; 2016. (Série Estudos de Caso Sobre o Programa Mais Médicos, 2). in the city of Rio de Janeiro showed similar findings in regard to the challenges of dealing with drug and alcohol problems, which were unfamiliar to the physicians from the PMM.

Physicians and supervisors both felt that even in territories with serious social and epidemiological problems, the family health teams cover an excessive number of users. The population surplus hinders the teams’ capacity to develop comprehensive practices. Santos ³¹31. Santos AM. Posição da Estratégia Saúde da Família na coordenação do cuidado no município sede de Região de Saúde - o caso de Vitória da Conquista. In: Almeida PF, Santos AM, Souza MKB, organizadores. Atenção primária à saúde na coordenação do cuidado em Regiões de Saúde. Salvador: Edufba; 2015. p. 205-37. shows that UBS with excessively heavy demand display precarious physician-patient bonds and fail to ensure a continuous relationship over time or access to timely first contact, which can reduce the FHS to a “complaint-management” outpatient clinic with disease-centered care.

Corroborating previous studies, we found a receptiveness to the spontaneous and scheduled demand based on strategies for its absorption ²¹21. Comes Y, Trindade J, Pessoa VM, Barreto ICHC, Shimizu HE, Dewes D, et al. A implementação do Programa Mais Médicos e a integralidade nas práticas da Estratégia Saúde da Família. Ciênc Saúde Coletiva 2016; 21:2727-36.^,2323. Pereira LL, Pacheco L. O desafio do Programa Mais Médicos para o provimento e a garantia da atenção integral à saúde em áreas rurais na região amazônica. Interface (Botucatu, Online) 2017; 21:1181-92.^,2626. Organização Mundial da Saúde, Organização Pan-Americana da Saúde. Programa Mais Médicos no Município do Rio de Janeiro: mais acesso, equidade e resolutividade na APS. Brasília: Organização Pan-Americana da Saúde; 2016. (Série Estudos de Caso Sobre o Programa Mais Médicos, 2).. Follow-up of various population groups is another positive aspect of the practices by physicians in the PMM.

Difficulties in the follow-up of mental health cases reflect inadequate training to deal with these problems, similar to Brazilian physicians, who often resist addressing mental health problems in the context of the FHS ³²32. Lima ED. Imaginário social sobre a loucura: cultura e práticas de cuidado em saúde mental. Curitiba: Appris; 2016.. Violence and precarious living conditions in large Brazilian metropolises, as in this study’s context, not only fuels the incidence of mental problems, but also complexifies them ²⁶26. Organização Mundial da Saúde, Organização Pan-Americana da Saúde. Programa Mais Médicos no Município do Rio de Janeiro: mais acesso, equidade e resolutividade na APS. Brasília: Organização Pan-Americana da Saúde; 2016. (Série Estudos de Caso Sobre o Programa Mais Médicos, 2)..

Insufficient coordination of care, a common problem in the SUS ³³33. Almeida PF, Santos AM, Oliveira SS, Heringer A, Martins Júnior DF. Posição da Estratégia Saúde da Família na coordenação do cuidado no município sede de Região de Saúde - o caso de Feira de Santana. In: Almeida PF, Santos AM, Souza MKB, organizadores. Atenção Primária à Saúde na coordenação do cuidado em Regiões de Saúde. Salvador: Edufba; 2015. p. 147-73., also appeared as a weakness in the current study. According to Almeida et al. ³³33. Almeida PF, Santos AM, Oliveira SS, Heringer A, Martins Júnior DF. Posição da Estratégia Saúde da Família na coordenação do cuidado no município sede de Região de Saúde - o caso de Feira de Santana. In: Almeida PF, Santos AM, Souza MKB, organizadores. Atenção Primária à Saúde na coordenação do cuidado em Regiões de Saúde. Salvador: Edufba; 2015. p. 147-73., the referral guide is a poor instrument for dialogue between specialists and generalists and requires users to serving as messengers of their own clinical data, besides placing them in the middle of disputes for professional recognition between specialists and basic care physicians, which was also evidenced here in the PMM.

The study showed predominantly favorable responses in relation to the Cuban physicians’ collaboration with nursing staff, community health agents, and the NASF, in keeping with other studies on practices in the PMM ²¹21. Comes Y, Trindade J, Pessoa VM, Barreto ICHC, Shimizu HE, Dewes D, et al. A implementação do Programa Mais Médicos e a integralidade nas práticas da Estratégia Saúde da Família. Ciênc Saúde Coletiva 2016; 21:2727-36.^,2222. Pereira LL, Silva HP, Santos LMP. Projeto Mais Médicos para o Brasil: Estudo de caso em comunidades quilombolas. Rev ABPN 2015; 7:28-51.^,2626. Organização Mundial da Saúde, Organização Pan-Americana da Saúde. Programa Mais Médicos no Município do Rio de Janeiro: mais acesso, equidade e resolutividade na APS. Brasília: Organização Pan-Americana da Saúde; 2016. (Série Estudos de Caso Sobre o Programa Mais Médicos, 2).. Cultural differences, especially regarding language and the roles of different health workers in the health team, were scarcely important and were attenuated over time, consistent with the findings by Comes et al. ²¹21. Comes Y, Trindade J, Pessoa VM, Barreto ICHC, Shimizu HE, Dewes D, et al. A implementação do Programa Mais Médicos e a integralidade nas práticas da Estratégia Saúde da Família. Ciênc Saúde Coletiva 2016; 21:2727-36.. The NASF was called on extensively, with regular and frequent relations for inter-consultation and pedagogical support, notably for mental health and social assistance. Previous studies have shown that contact with primary health care physicians by the NASF teams is unusual, and that what predominates is referral, with inter-consultation occurring mainly between nurses and community health agents ³²32. Lima ED. Imaginário social sobre a loucura: cultura e práticas de cuidado em saúde mental. Curitiba: Appris; 2016..

The physicians from the PMM analyze the population’s health indicators and develop planned activities. This kind of work has also been found by other studies ²¹21. Comes Y, Trindade J, Pessoa VM, Barreto ICHC, Shimizu HE, Dewes D, et al. A implementação do Programa Mais Médicos e a integralidade nas práticas da Estratégia Saúde da Família. Ciênc Saúde Coletiva 2016; 21:2727-36.^,2323. Pereira LL, Pacheco L. O desafio do Programa Mais Médicos para o provimento e a garantia da atenção integral à saúde em áreas rurais na região amazônica. Interface (Botucatu, Online) 2017; 21:1181-92.^,2626. Organização Mundial da Saúde, Organização Pan-Americana da Saúde. Programa Mais Médicos no Município do Rio de Janeiro: mais acesso, equidade e resolutividade na APS. Brasília: Organização Pan-Americana da Saúde; 2016. (Série Estudos de Caso Sobre o Programa Mais Médicos, 2).. The preventive focus, an established principle of the Cuban National Health System, especially in primary health care, where the practice is systematized through action planning mechanisms ²³23. Pereira LL, Pacheco L. O desafio do Programa Mais Médicos para o provimento e a garantia da atenção integral à saúde em áreas rurais na região amazônica. Interface (Botucatu, Online) 2017; 21:1181-92., may be a practice that favors the physicians from the PMM.

In the use of clinical protocols, elements of professional conduct and the physician-patient relationship related to quality of care ¹⁷17. Silva Junior AG, Mascarenhas MTM. Avaliação da atenção básica em saúde sob a ótica da integralidade: aspectos conceituais e metodológicos. In: Pinheiro R, Mattos RA, organizadores. Cuidado: as fronteiras da integralidade. Rio de Janeiro: Abrasco/São Paulo: Editora Hucitec; 2004. p. 241-57. were present, such as technical skill, clinical actions associated with the social approach (especially in the home visits), valorization of the clinical examination, and rational use of diagnostic resources.

In short, the work by the Cuban physicians in Brazil’s PMM presents elements consistent with the comprehensiveness of the practices, according to the concept adopted in this study, with the provision of a wide range of actions and services, in keeping with the health problems’ complexity and the plurality of scenarios. These professionals display a striking capacity for community interaction, a preventive focus, planning of activities, and good interpersonal relations, showing attitudes and techniques of solidarity, bonding, community accountability, and quality of care.

Challenges were also identified in the promotion of participatory practices in the community, patient autonomy in clinical decisions, more effective management of psychological problems, systematization of approach tools (person-centered and for more vulnerable cases, for example), and training in invasive procedures in basic care. The learning processes established in the Program provide possibilities for improvement and for overcoming these obstacles.

The study’s results give strong evidence that the PMM has reached beyond increasing access to consultations ¹³13. Secretaria de Gestão e Educação do Trabalho em Saúde, Ministério da Saúde. Programa Mais Médicos - dois anos: mais saúde para os brasileiros. Brasília: Ministério da Saúde; 2015. and procedures and decreasing inequalities in the distribution of physicians ¹²12. Girardi SN, Stralen ACS, Cella JN, Maas LWD, Carvalho CL, Faria EO. Impacto do Programa Mais Médicos na redução da escassez de médicos em atenção primária à saúde. Ciênc Saúde Coletiva 2016; 21:2675-84.. The practice by Cuban physicians in the PMM in the case studied here allowed supplying comprehensive health care, thereby helping to strengthen a comprehensive concept of primary health care and of the SUS.

Acknowledgments

The authors wish to thank the physicians and supervisors of the More Doctors Program and the Rio de Janeiro Municipal Health Department for their support.

References

Publication Dates

History