Physicians and their representative organizations occupy a central place in the construction trajectories of public health systems. At the international level, comparative studies emphasize the importance of the relations between the state and medical organizations for different health policy orientations and paths in specific institutional contexts ¹1. Immergut EM. Health politics: interests and institutions in Western Europe. New York: Cambridge University Press; 1992.. They also highlight the tensions involving the regulation of medical work (contract modes and employment types, forms of payment, among others) and professional autonomy (such as defining the attribution and scope of medical activities), associated with governmental proposals for reorienting and expanding the public health care system ²2. Moran M. Governing the health care state: a comparative study of the United Kingdom, the United States, and Germany. Manchester: Manchester University Press; 1999.^,33. Giaimo S. Markets and medicine: the politics of health care reform in Britain, Germany, and the United States. Ann Arbor: University of Michigan Press; 2009..

In Brazil, the subject has been the object of many works that analyze physicians’ political practice, influences and positions in different historical moments, such as 1920 and 1930 ⁴4. Castro MHG. Conflitos e interesses na implementação da reforma da política de saúde. Saúde Debate 1992; 35:15-21.^,55. Teixeira CRRR. A reforma Pedro Ernesto (1933): perdas e ganhos para os médicos do Distrito Federal [Dissertação de Mestrado]. Rio de Janeiro: Casa de Oswaldo Cruz, Fundação Oswaldo Cruz; 2004.^,66. Pereira Neto AF. A profissão médica em questão (1922): dimensão histórica e sociológica. Cad Saúde Pública 1995; 11:600-15., 1970 and 1980 ⁷7. Donnangelo MCF. Medicina e sociedade. O médico e seu mercado de trabalho. São Paulo: Pioneira; 1975.^,88. Campos GWS. Os médicos e a política de saúde: entre a estatização e o empresariamento: a defesa da prática liberal da medicina. São Paulo: Editora Hucitec; 1988.^,99. Teixeira SMF, Gerschman S. Movimentos sociais, construção de hegemonia e formulação de políticas: um estudo sobre o movimento médico e os movimentos populares em saúde. Relatório parcial da pesquisa. Rio de Janeiro: Núcleo de Estudos Político-sociais em Saúde, Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz; 1990.^,1010. Lobato LVC. Corporação médica e reforma sanitária [Dissertação de Mestrado]. Rio de Janeiro: Escola de Administração Pública, Fundação Getúlio Vargas; 1994. and during the initial implementation of the Brazilian Unified National Health System (SUS, in Portuguese) in the early 1990s ⁴4. Castro MHG. Conflitos e interesses na implementação da reforma da política de saúde. Saúde Debate 1992; 35:15-21.. Beginning in 2013, when the More Doctors Program (PMM, in Portuguese) was launched, these analyses once again became the focus of attention in the Collective Health agenda, showing confrontations between the government and the medical establishment in the process of formulating and implementing this policy ¹¹11. Alessio MM, Sousa MF. Programa Mais Médicos: elementos de tensão entre governo e entidades médicas. Interface (Botucatu, Online) 2017; 21 Suppl 1:1143-56.^,1212. Gomes LB, Merhy EE. Uma análise da luta das entidades médicas brasileiras diante do Programa Mais Médicos. Interface (Botucatu, Online) 2017; 21 Suppl 1:1103-14.^,1313. Dias HS. Do diálogo à ruptura: interações governo-corporação médica na política nacional de trabalho e educação na saúde [Tese de Doutorado]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2018..

The year 2019 begins with a number of challenges for the national health policy and SUS. Among these is the challenge of guaranteeing the replacement of more than 8,000 physicians who began to leave the country in November 2018 due to the end of the technical cooperation agreement between Cuba and Brazil, mediated by the Pan-American Health Organization, within the scope of the PMM. According to a technical statement released by the Brazilian Public Health Association (Abrasco, in Portuguese), the departure of the Cuban physicians jeopardizes the health care of more than 23 million people living in 2,800 cities, places that stand out due to high indicators of poverty, needs and difficulty accessing primary health care (PHC) services ¹⁴14. Associação Brasileira de Saúde Coletiva. Nota Abrasco sobre a saída dos médicos cubanos do Mais Médicos. https://www.abrasco.org.br/site/outras-noticias/notas-oficiais-abrasco/nota-abrasco-sobre-saida-dos-medicos-cubanos-do-programa-mais-medicos-para-o-brasil/38190/ (acessado em 09/Dez/2018).
https://www.abrasco.org.br/site/outras-n... .

In order to meet the needs created by the Cuban professionals’ departure, the Health Ministry has opened a selection process that seeks to fill the vacancies with Brazilian physicians, in the cities included in the program. However, in early December 2018, information released by the Ministry reveals that, of the 34,653 physicians who had signed up, only 3,276 had begun to work and, of these, the number who quit was quite significant (http://portalms.saude.gov.br/noticias/agencia-saude/44870-com-desistentes-cerca-de-200-vagas-voltam-a-edital-do-mais-medicos).

Amid this scenario, we highlight the medium-term measures proposed by Abrasco ¹⁴14. Associação Brasileira de Saúde Coletiva. Nota Abrasco sobre a saída dos médicos cubanos do Mais Médicos. https://www.abrasco.org.br/site/outras-noticias/notas-oficiais-abrasco/nota-abrasco-sobre-saida-dos-medicos-cubanos-do-programa-mais-medicos-para-o-brasil/38190/ (acessado em 09/Dez/2018).
https://www.abrasco.org.br/site/outras-n... . They will required negotiations between federal entities, government branches (Executive, Legislative and Judiciary), the new administration and civil society organizations in order to solve structural problems, such as those related to training, providing and retaining Brazilian physicians and to guarantee a greater adherence by physicians to SUS requirements. Negotiations will take place within a context of restrictions of financial resources and worsening life conditions in the country, which increases responsibilities and expectations regarding agreements and proposals that may satisfactorily respond to the population’s collective interests.

The January 2019 issue of CSP seeks to contribute to this debate by publishing the thematic section Physicians in Primary Health Care. The section includes four articles written by PHC physicians who reflect on the experience and professional dilemmas, considering different characteristics of the health systems in Portugal, Brazil, Canada and Chile that condition medical practice.

Martin Roland comments on the articles ¹⁵15. Roland M. 40 years on. Has the vision of Alma-Ata been realized? Cad Saúde Pública 2019; 35:e00212218.. He recognizes the advances made, but suggests immense gaps that still persist, forty years after Alma-Ata Conference, for implementing a public, universal and integral PHC in these countries.

With this year’s cover photos, we intend to honor the work of all health professionals who dedicate an important part of their lives to SUS!

References

Publication Dates