Abstract

Introduction

All over the world, health systems have been going through deep changes due to demographic, epidemiologic and economic transitions¹1 Crisp N, Chen L. Global supply of health professionals. N Engl J Med. 2013; 370(23): 950-7.. Over the last few years, the Brazilian government has been developing a series of actions aiming the restructuring of the Brazilian National Health System (SUS) so to prioritize Primary Care and face the development limitations of that which is established as the preferred entryway of SUS. In its 25 year of existence, SUS has made possible an importante increase in the access of the Brazilian population to healthcare²2 Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet 2011; 377(9779):1778-97.. However, people living in remote and vulnerable communitys still face important difficulties in the access to health services.

Geographic inequalities in the distribution of physicians can be found in several countries and regions³3 Póvoa L, Andrade MV. Distribuição geográfica dos médicos no Brasil: uma análise a partir de um modelo de escolha locacional. Cad Saude Publica. 2006; 22(8):1555-64.^,44 Grobler L, Marais B, Mabunda SA, Marindi PN, Reuter H, Volmink J. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database Syst Rev. 2009; 21(1):1-25. CD005314.. The World Health Organization estimates that 50% of the world’s population lives in remote rural areas, but these areas are served by less than 25% of the medical workforce⁵5 Araújo E, Maeda A. How to recruit and retain health workers in rural and remote areas in developing countries. In: Bank W, organizador. Relatório. Washington (DC): World Bank; 2013 [acesso 2014 Set 20]. Disponível em: https://openknowledge.worldbank.org/bitstream/handle/10986/16104/78506.pdf?sequence=1
https://openknowledge.worldbank.org/bits... . Many countries are seeking solutions to increase the coverage of primary care in vulnerable areas attracting health professionals to these regions⁶6 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(9613):668-74.^,77 Buykx P, Humphreys J, Wakerman J, Pashen D. Systematic review of effective retention incentives for health workers in rural and remote areas: towards evidence-based policy. Aust J Rural Health. 2010; 18(3):102-9.^,88 Dolea C, Stormont L, Braichet J. Evaluated strategies to increase attraction and retention of health workers in remote and rural areas. Bull World Health Organ. 2010; 88(5):379-85.. These strategies include: regulation policies such as mandatory service; monetary incentives such as scholarships; non-monetary incentives such as the extension of the permanent visa for foreigners⁹9 Lehmann U, Dieleman M, Martineau T. Staffing remote rural areas in middle - and low-income countries: a literature review of attraction and retention. BMC Health Serv Res. 2008; 8:19.^,1010 Viscomi M, Larkins S, Gupta T. Recruitment and retention of general practitioners in rural Canada and Australia: a review of the literature. Can J Rural Med. 2013; 18(1):13-23.. In spite of the importance of human resources for the access to health and of previous policies made the Brazilian Government regarding the inequality of the distribution of physicians and the strengthening of primary care, none of them reached the coverage, magnitude and speed of the “Mais Medicos” Program, including its concern with the need of changes in medical education.

These transformations generated deep discussions both in national and international scopes on the different strategies that seek to increase access to health services in vulnerable areas and to restructure health systems through the strengthening of primary care. In face of the situation, this paper makes a comparative analysis between service organization models of three countries: Australia, United States of America and Brazil. The motivation for opening the present debate refers to the need of the Secretariat of Management of Labor and Education in Health (SGTES) at the moment in which the “Mais Médicos” has completed on year of its implantation, to learn and have a dialog with the countries that present different models of provision and fixation of physicians in distant areas and greater vulnerability regions. Thus, we were inspired by the debate and presentations of “International Seminar of the Education and Work Integration Process and the Impact on Care: the role of permanent trainning and education in the care network ordained by primary care”, promoted by SGTES on September 17^th and 18^th of 2014 in Brasília. The study was conducted by means of bibliographic research, with academic literature revision in LILACS, MEDLINE and EMBASE, as well as documents, reports and presentations in English, Spanish and Portuguese were analyzed.

Australia

Australia has a mix health system with private and public participation. Founded in 1984, Medicare offers universal health coverage to the Australian population through public funding. Medicare is the main financier of health primary care in Australia¹¹11 Wiese M, Jolley G, Baum F, Freeman T, Kidd M. Australia’s systems of primary healthcare - the need for improved coordination and implications for Medicare Locals. Aust Fam Physician. 2011; 40(12):995-9.. A third of the Australian population lives in rural zone, of which 20% is dispersed in 1,500 rural communities with under 5,000 inhabitants¹²12 Australian Institute of Health and Welfare. Rural, regional and remote health: indicators of health status and determinants of health [Internet]. Canberra: Australian Institute of Health and Welfare; 2008 [acesso 2014 Set 20] (Rural Health Series; 9). Disponível em: http://www.aihw.gov.au/publication-detail/?id=6442468076
http://www.aihw.gov.au/publication-detai... . Many of these communities suffer shortage of physicians, in which the proportion of physicians per 1,000 inhabitants is 1.8 for urban areas, and 0.9 for rural communities¹⁰10 Viscomi M, Larkins S, Gupta T. Recruitment and retention of general practitioners in rural Canada and Australia: a review of the literature. Can J Rural Med. 2013; 18(1):13-23..

As a strategy to retain and fixate health professionals in remote regions, the Australian Government implemented a series of measures and programs. Among the most relevant programs for this discussion are the Overseas Trained Doctors (OTD) and the Rural Clinical Training and Support (RCTS)¹³13 Australian Government. Department of Health. Review of the Australian Government Health Workforce Programs [Internet]. Canberra: Department of Health; 2013 [acesso 2014 Set 20]. Disponível em: http://www.health.gov.au/internet/publications/publishing.nsf/Content/work-review-australian-government-health-workforce-programs-toc~chapter-4-addressing-health-workforce-shortages-regional-rural-remote-australia~chapter-4-health-education-strategies-rural-distribution
http://www.health.gov.au/internet/public... . OTD is governed by the “19AB Act” of January 1^st 1997, and is a program designed to attract physicians graduated overseas to work in remote areas of Australia. The eligible professionals for the program are: general practitioner physicians, hospital general practitioner physicians and specialist physicians.

The highlight axis referes to general practitioner physicians being coordinated by the Rural Work Agencies (Northeast, New South Wales, Queensland, Victoria, South Australia, West Australia and Tasmania Agencies) and by the Australian Medical Council, along with Human Resource areas of MEDICARE. The necessary requirements for the practice of medicine for foreigners in Australia are: a) approval on the on-line test; b) proof of proficiency in English; c) evaluation of curriculum criteria for acceptance in foreign universities previously approved by MEDICARE; d) individual contract with an employer; e) obtaining a temporary work visa-457; f) approval in the interview for obtaining the MEDICARE registration; g) payment of fees¹⁴14 Australian Government. Department of Health, Rural and Regional Health Austrália. Rural Health Workforce Strategy (RHWS) Incentive Programs [Internet]. Canberra: Department of Health; 2014 [acesso 2014 Set 20]. Disponível em: http://www.ruralhealthaustralia.gov.au/internet/rha/publishing.nsf/Content/RHWS_incentive_programs
http://www.ruralhealthaustralia.gov.au/i... .

The participant initially has restrictions to perform its labor activities, being supervised by other physicians and their license does not allow unrestricted professional practice, so that their placement must be in areas the Australian Government considers being of greater vulnerability for a period of 10 years. During this period it is offered to the participants the possibility of technical improvement by education offers and classes for the complete revalidation of the participant’s diploma in the country. The financial benefits vary according to the region chosen by the candidate, so that the benefits are higher in areas of greater need¹⁵15 Australian Government. Department of Health. Work as a doctor in Australia [Internet]. Canberra: Department of Health; 2014 [acesso 2014 Set 20]. Disponível em: http://www.doctorconnect.gov.au/internet/otd/publishing.nsf/Content/home
http://www.doctorconnect.gov.au/internet... .

The program is three years away of turning 20, so it is possible to evaluate that the fixation of participants in Australia is still suffering difficulties to retain the participants in rural settings when the 10 year period of the contract is up. The problem is related to several personal, economical and geographic factors which characterize the vulnerable areas of the country as it occurs in the other countries that have established foreign professional recruitment policies as well¹⁶16 Wilson N, Couper E, Reid S J, Fish T, Marais BJ. A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. Rural Remote Health. 2009; 9(2):1060..

Most of Australian medical schools receive funding from the Government through the Rural Clinical Training and Support (RCTS) program, which foresees funding for strengthening of training of clinicians in rural areas. The funding is directed for medical schools to: select students from rural areas, provide rural apprenticeship and internship for all medicine students and the perfect the support system for rural medicine students and teachers¹⁷17 Clarke TR, Freedman SB, Croft AJ, Dalton HE, Luscombe GM, Brown AM, et al. Medical graduates becoming rural doctors: rural background versus extended rural placement. Med J Aust. 2013; 199(11):779-782.. Amogst the goals of the RCTS are: 25% of medicine students to perform at least one year of their clinical training in a rural area and 25% of Commonwealth funded students to come from rural areas. Currently, 90% of Australian medical schools participate in this program. It is important to highlight that the Australian Government has been encouraging students to study in university campi near their original regions¹³13 Australian Government. Department of Health. Review of the Australian Government Health Workforce Programs [Internet]. Canberra: Department of Health; 2013 [acesso 2014 Set 20]. Disponível em: http://www.health.gov.au/internet/publications/publishing.nsf/Content/work-review-australian-government-health-workforce-programs-toc~chapter-4-addressing-health-workforce-shortages-regional-rural-remote-australia~chapter-4-health-education-strategies-rural-distribution
http://www.health.gov.au/internet/public... .

The United States of America

The American health system is quite different from Brazil and Australia, as there is no public system of universal health coverage. Most of the US citizens are covered by health plans funded by their employers. Individuals over 65 years of age may register in the Medicare Program which is funded by the Government. Low income families, children, pregnant women and handicapped people are eligible for Medicaid, also funded by the Government. The American Government also manages the S-Chip, which provides coverage for children of low income parents, but not sufficiently low to be eligible for Medicaid. Veterans of the Armed Forces also have medical care through Government financing¹⁸18 World Health Organization. Health system in transition, United States of America: health system review. WHO [Internet]. 2013 [acesso 2014 Set 20]. Disponível em: http://www.euro.who.int/data/assets/pdf_file/0019/215155/HiT-United-States-of-America.pdf
http://www.euro.who.int/data/assets/pdf_... .

The Affordable Care Act (Obamacare), approved in March 2010, is considered the greatest change in the US health system since the foundation of Medicaid and Medicare in 1965¹⁹19 United States of America. Public Law 111-148 111th, Mar 23, 2010 [Internet]. Washington (DC): United States Government Printing Office; 2010 [acesso 2014 Set 20]. Disponível em: http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
http://www.gpo.gov/fdsys/pkg/PLAW-111pub... . It is a Federal regulation law which aims to expand the coverage of public and private insurance, control health insurance prices, and assure basic treatments and even hospital admissions for serious diseases to the insured, all of this regardless of sex or, more importantly, of pre-existing conditions. At the individual level, the implementation is guaranteed through the obligation of acquiring health insurance. At state level, the States that join the project receive more federal resources for programs targeted to public health¹⁹19 United States of America. Public Law 111-148 111th, Mar 23, 2010 [Internet]. Washington (DC): United States Government Printing Office; 2010 [acesso 2014 Set 20]. Disponível em: http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
http://www.gpo.gov/fdsys/pkg/PLAW-111pub... .

Unlike Brazil and Australia, medical education in the US is offered at the postgrad level. This means that if a student desires to become a physician he or she must take an undergraduate course completing the prerequisitions to access medical school, with an average duration of 4 years. In medical school, the students, now graduate students, spend two years in classroom and laboratories and another two years getting to know the profession up close, in hospitals, before moving forward to medical residence. In total, it takes eight years to train a physician in the US²⁰20 U.S. National Library of Medicine. Doctor of Medicin profession [Internet]. Bethesda: NIH; 2013 [acesso 2014 Set 20]. Disponível em: http://www.nlm.nih.gov/medlineplus/ency/article/001936.htm
http://www.nlm.nih.gov/medlineplus/ency/... ^,2121 Salsberg ES, Wing P, Dionne MG, Jemiolo DJ. Graduate Medical Education and Physician Supply in New York State. JAMA.1996; 276(9):683-8.. Most of the institutions that train physicians are private, with high yearly tuitions. A great number of students get loans in order to be able to afford their trainning, and they usually begin to pay it after graduation. In this context, it is not difficult to realize that those who study medicine end their studies with a substantial debt. According to the American Association of Medical Colleges, it is estimated that four years of private medical school has an average cost of 278 thousand dollars²²22 Kahn MJ, Ronald J, Markert FA, Lopez Specter S, Randall H, Krane, K. Is medical student choice of a Primary Care Residency influenced by debt? Med Gen Med. 2006; 8(4):18.^,2323 Lorin J. Medical school at $ 278,000 means even bernanke son has debt. Bloomberg [Internet]. 2013 [acesso 2014 Set 20]. Disponível em: http://www.bloomberg.com/news/2013-04-11/medical-school-at-278-000-means-even-bernanke-son-carries-debt.html
http://www.bloomberg.com/news/2013-04-11... .

Despite recent initiatives in the US for greater State regulation over the health system, there are only few initiatives to regulate the provision of health professionals in remote and vulnerable regions. The main initiatives to reduce inequalities in the distribution of physicians in the US are made through the National Health Service Corps (NHSC) and the Conrad 30 Program. Since 1972, NHSC offers scholarships and student loan debt payment programs to the professionals willing to render health services of primary health care for communities in need. After graduation (and the residency for physicians, osteopaths and dentistry students), the student must apply for the previously approved vacancies in areas in need²⁴24 United States Department of Health and Human Services, division of Health Resources and Services Administration, Bureau of Clinician Recruitment and Service. National Health Service Corps [acesso 2014 Set 20]. Disponível em: http://nhsc.hrsa.gov/
http://nhsc.hrsa.gov/... .

The candidate who obtained a scholarship from NHSC and chooses a specialty that is not family and community general practitioner, or who does not fulfill service requirements, shall reimburse the government in three installments with interest. In the student debt payment program, students apply after graduation and the NHSC pays up to US$60 thousand of the debt every two years. There is also the option to work at a NHSC approved location for 5 years, which offers the student the potential to receive US$ 170 thousand as student loan payment²⁴24 United States Department of Health and Human Services, division of Health Resources and Services Administration, Bureau of Clinician Recruitment and Service. National Health Service Corps [acesso 2014 Set 20]. Disponível em: http://nhsc.hrsa.gov/
http://nhsc.hrsa.gov/... . It is important to highlight that the areas with shortage of health professionals are mapped by the regional offices of NHSC.

Through the Conrad 30 Program, the United States Government allows physicians that are in the US with a J-1 visa (for temporary training) to remain in the country after the exchange program is over to act in areas in need²⁵25 United States Department of Homeland Security, U.S. Citizenship and Immigration Services. Conrad 30 Program [Internet]. West Bloomfield; 2014 [acesso 2014 Set 20]. Disponível em: http://www.uscis.gov/working-united-states/students-and-exchange-visitors/conrad-30-waiver-program
http://www.uscis.gov/working-united-stat... . It is worth mentioning that the individuals who enter the US with a J-1 visa should normally return to their countries of origin and reside there for at least 2 years. Through the Conrad 30 Program, the physician’s tie is with a local employer and not the federal government. After the fulfillment of the contract’s work conditions for the minimum period of three years, the physicians may apply for an emigrant visa or a permanent residence visa²⁵25 United States Department of Homeland Security, U.S. Citizenship and Immigration Services. Conrad 30 Program [Internet]. West Bloomfield; 2014 [acesso 2014 Set 20]. Disponível em: http://www.uscis.gov/working-united-states/students-and-exchange-visitors/conrad-30-waiver-program
http://www.uscis.gov/working-united-stat... . Approximately 25% of the physicians in activity in the US are foreigners²⁶26 American Medical Association. IMGs in the U.S. physician workforce discussion paper - 2009 edition [Internet]. Chicago: AMA; 2014 [acesso 2014 Set 20]. Disponível em: http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/international-medical-graduates/imgs-in-united-states.page?
http://www.ama-assn.org/ama/pub/about-am... .

Brazil

The Brazilian National Health System (SUS) is formed by the set of all health actions and services offered by federal, state and municipality health organs and institutions, being allowed for private sector to participate in this system in a complementary form. SUS was instituted by the 1988 Federal Constitution, which determined health is a right for all and the duty of the State, being one of the largest public health systems in the world.

In spite of SUS having made possible an important increase in access to health care for the Brazilian population, people living in remote and vulnerable communities still face poor access to operative health services. The shortage of physicians has always been an important aggravation to this problem, as it was made clear by the campaign “Where is the physician?” (or "Cadê o médico?", in Portuguese), held by the National Mayors Front (Frente Nacional de Prefeitos), during the meeting of Mayors that took place in Brasilia in January 2013²⁷27 Carvalho MS, Sousa MF. Como o Brasil tem enfrentado o tema provimento de médicos? Interface (Botucatu) [Internet]. 2013 [acesso 2014 Set 20]; 17(47):913-26. Disponível em: http://dx.doi.org/10.1590/1807-57622013.0403
http://dx.doi.org/10.1590/1807-57622013.... .

The “Mais Médicos” Program was introduced in Brazil in July 2013, as part of a series of measures to fight inequalities of access to operative primary care²⁸28 Lei nº 12.871, de 22 de outubro de 2013. Institui o Programa Mais Médicos, altera as Leis n. 8.745, de 9 de dezembro de 1993, e n. 6.932, de 7 de julho de 1981, e dá outras providências. Diário Oficial da União. 23 Out 2013 [acesso 2014 Maio 22]. Disponível em: http://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?jornal=1&pagina=1&data=23/10/2013.
http://pesquisa.in.gov.br/imprensa/jsp/v... . The Program has been structured on three axis of action. The first one is the investment in improving the health care network infrastructure, particularly in primary care units. The second one is the extension and education reforms of the medical courses and medical residence in the country. The third one, named“Projeto Mais Médicos para o Brasil”, or “More Physicians for Brazil Project” (PMMB), is an emergency physician provision program for vulnerable areas.

It is important to highlight that in Brazil, before the PMMB, there were several initiatives to attract and fixate health professionals in remote areas, such as the Internalization of Health and Sanitation Action Program (Programa de Interiorização das Ações de Saúde e Saneamento - PIASS - 1976), the Internalization of the Brazilian National Health System (Programa de Interiorização do Sistema Único de Saúde - PISUS - 1993), the Internalization of the Work in Health Program (Programa de Interiorização do Trabalho em Saúde - PITS - 2001), and recently the Primary Care Professional Appreciation Program (Programa de Valorização dos Profissionais da Atenção Básica - PROVAB)²⁷27 Carvalho MS, Sousa MF. Como o Brasil tem enfrentado o tema provimento de médicos? Interface (Botucatu) [Internet]. 2013 [acesso 2014 Set 20]; 17(47):913-26. Disponível em: http://dx.doi.org/10.1590/1807-57622013.0403
http://dx.doi.org/10.1590/1807-57622013.... . Since 2011, PROVAB has been recruiting and allocating physicians, nurses and dentists to work in vulnerable areas. However, as in previous programs, the participation of the physician professional in PROVAB has been below the local or regional needs. Between 2011 and 2013, the participation had an important increase from 350 to 3,550 physicians. It is worth mentioning that by 2013 the hiring was no longer made the municipality, but by the Federal Government, there was an increase of the grant and an extra 10% offer on the grading for the medical residence test²⁹29 Portaria Interministerial MEC/MS nº 2.087, de 1º de setembro de 2011b. Institui o Programa de Valorização do Profissional da Atenção Básica. Diário Oficial da União. 2 Set 2011 [acesso 2014 Maio 22]. Disponível em: http://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?jornal=1&pagina=92&data=02/09/2011
http://pesquisa.in.gov.br/imprensa/jsp/v... . Besides, in 2013 the primary care specialization started to be mandatory.

In spite of the above-mentioned programs having contributed to attract professionals to remote areas, none was able to get it to the necessary magnitude to supply the municipalities’ demands. It was only through PMMB that the recruiting and allocation of physicians had the necessary dimension to fill the municipalities’ demands³⁰30 Girardi SN, Carvalho CL, Araújo JF, Farah JM, Wan der Maas L, Campos LAB. Índice de escassez de médicos no Brasil: estudo exploratório no âmbito da Atenção Primária. In: Pierantoni CR, Dal Poz MR, França T, organizadores. O trabalho em Saúde: abordagens quantitativas e qualitativas. Rio de Janeiro: Cepesc/IMS/UERJ, ObservaRH; 2011. p. 171-86.. In less than a year, PMMB recruited 14,462 physicians and allocated in 3,785 municipalities. The grand innovation of PMMB refers to the strategy of international calls, when besides the 1,846 Brazilian physicians, the program started to count on 12,616 foreign physicians from 49 countries participating in the program, as seen in Picture 1. Out of the foreign physicians that operate in PMMB, 11,429 are Cuban physicians who were recruited through a partnership between the Ministry of Health of Brazil and the Pan-American Health Organization, and the later one with the Ministry of Public Health of Cuba (Ministerio de Salud Pública de Cuba)³¹31 Ministério da Saúde. Apresentação de um ano do Programa Mais Médicos [Internet]. Brasília (DF): MS; 2014 [acesso 2014 Set 22]. Disponível em: http://portalsaude.saude.gov.br/images/pdf/2014/setembro/04/apresentacao-COLETIVA-1-ANO-MAIS-M--DICOS---04-09-1.pdf
http://portalsaude.saude.gov.br/images/p... .

Municipalities and indigenous sanitary districts that fitted in one of the six vulnerability profiles (Table 1) were able to participate in the program. As part of the registration process, the managers were required to identify the number of necessary physicians according to a maximum number based on the population of the municipality and for whom they would be capable of providing adequate conditions for the activities. Physicians eligible for participation were: Brazilian physicians graduated in Brazil or overseas, foreign physicians graduated in Brazil or overseas as long as coming from countries where the per capita number of physicians was over 1.8 per thousand, which corresponds to the per capita number of physicians in Brazil before the PMM³²32 Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Edital n° 50, de 16 de agosto de 2013. Adesão dos médicos ao Projeto Mais Médicos para o Brasil. Diário Oficial da União. 19 Ago 2013 [acesso 2014 Maio 22]. Disponível em: http://portalsaude.saude.gov.br/index.php/cidadao/acoes-e-programas/mais-medicos/mais-sobre-mais-medicos/5955-documentos
http://portalsaude.saude.gov.br/index.ph... .

The allocation criteria included the preferences of registered physicians, the place of graduation, the age of the candidate and if the physician had worked in the “Family Health Strategy” (Estratégia de Saúde da Família), making it impossible for the physicians to stay in the same municipality of the physicians that were already working in primary care. Both physicians and municipal managers had to confirm the results of the allocation. The percentage of population covered by physicians of the PMMB may be observed in Picture 2.

Through joint effort between the Ministry of Health and the Ministry of Education, so that they may begin their activities in Brazil, foreign physicians go through four weeks of intensive training offered by Brazilian universities, which addresses clinical language, the national assistance protocols and SUS³²32 Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Edital n° 50, de 16 de agosto de 2013. Adesão dos médicos ao Projeto Mais Médicos para o Brasil. Diário Oficial da União. 19 Ago 2013 [acesso 2014 Maio 22]. Disponível em: http://portalsaude.saude.gov.br/index.php/cidadao/acoes-e-programas/mais-medicos/mais-sobre-mais-medicos/5955-documentos
http://portalsaude.saude.gov.br/index.ph... . The approved physicians receive a temporary registration for medical performance named “Unique Record of the Ministry of Health” (Registro Único do Ministério da Saúde - RMS). A special visa named VICAM was created for the physicians participating in the PMMB issued by the Ministry of Foreign Affairs.

The Brazilian universities assure continuous medical supervision for the participants. All participants get a tablet computer used to access extension courses offered by the SUS Open University (UNA-SUS)¹1 Crisp N, Chen L. Global supply of health professionals. N Engl J Med. 2013; 370(23): 950-7.. Physicians participating in the program must dedicate 32 hours a week to clinical activities and 8 hours to theoretical studies, as later they all shall undergo an evaluation. The signed contract has three year duration and may be renovated for additional three years.

Discussion

As we analyze the national and international processes of strengthening Primary Health Care and the provision of medical professionals in vulnerable areas, we should observe that, apart from the differences of context, the problematic has similarities. A recent study by the Organization for Economic Co-operation and Development (OECD) has shown that even with the increase of the total number of physicians, their distribution remains on the trend of great concentration in State capitals and areas of shortage in rural zones. Two other phenomena observed are the feminization and aging of the medical workforce³³33 Attal-Toubert K, Vanderschelden M. La démographie médicale à l’horizon 2030: de nouvelles projections nationales et régionales. Etud Résult {Internet]. 2009 [acesso 2014 Set 20] ; (679). Disponível em: http://www.drees.sante.gouv.fr/la-demographie-medicale-a-l-horizon-2030-de-nouvelles-projections-nationales-et-regionales-detaillees,5488.html
http://www.drees.sante.gouv.fr/la-demogr... .

More and more countries seek measures to assure the universality of health coverage, as well as the strengthening of a health system operative and adequate to the health needs of the population⁸8 Dolea C, Stormont L, Braichet J. Evaluated strategies to increase attraction and retention of health workers in remote and rural areas. Bull World Health Organ. 2010; 88(5):379-85.. The uneven distribution of health professionals, especially physicians, represents an important limition to reaching these objectives. As observed in the three countries analyzed, the iniquity problem in the distribution of health professionals is quite complex and a series of concomitant strategies has been used in order to mitigate it⁵5 Araújo E, Maeda A. How to recruit and retain health workers in rural and remote areas in developing countries. In: Bank W, organizador. Relatório. Washington (DC): World Bank; 2013 [acesso 2014 Set 20]. Disponível em: https://openknowledge.worldbank.org/bitstream/handle/10986/16104/78506.pdf?sequence=1
https://openknowledge.worldbank.org/bits... ^,3434 Huicho L, Dieleman M, Campbell J, Codjia L, Balabanova D, Dussault G, et al. Increasing access to health workers in underserved areas: a conceptual framework for measuring results. Bull World Health Organ. 2010; 88(5):357-63..

In short term, all three countries have made use of physician recruitment (national and foreign) within models that assure the attraction and retention of these professionals in remote areas. Brazilian and Australian models use a combination of financial and education incentives to attract and retain these professionals. Whereas the United States’ model has a greater focus on financial incentives and on the retention of foreign physicians that are already in the country being trained, through the extension of permanence visas. It is important to note that there are important limitations in the comparison of the attraction of a country of average income with one of high income. It is also necessary to elucidate the same limitations regarding the possibility between countries with extremely diverging political propositions towards the public health system.

In Australia, the wages of participant physicians of the Overseas Trained Doctors is variable, so that it is higher for those performing in remote rural zones. In Brazil, the wages of the participants of PMMB is the same; however the allowance for relocating is greater for participants who move to remote areas. In the country, there is also a university student loan payment system similar to the one of the United States NHSC, in which the physician that has at least a year of work in an area with shortage of physicians may have a reduction of 1% per month of the balance due to the Higher Education Student Financing Fund (Fundo de Financiamento ao Estudante do Ensino Superior - FIES)³⁵35 Lei n. 12.202, de 14 de janeiro de 2010. Altera a Lei n. 10.260, de 12 de julho de 2001, que dispõe sobre o Fundo de Financiamento ao Estudante do Ensino Superior - FIES (permite abatimento de saldo devedor do FIES aos profissionais do magistério público e médicos dos programas de saúde da família; utilização de débitos com o INSS como crédito do FIES pelas instituições de ensino; e dá outras providências). Diário Oficial da União. 15 Jun 2010 [acesso 2014 Maio 22]. Disponível em: http://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?jornal=1&pagina=3&data=15/01/2010
http://pesquisa.in.gov.br/imprensa/jsp/v... . Although there are few evaluations of health professional provision programs in areas in need, evidence suggests greater effectiveness of the programs combining different incentives⁷7 Buykx P, Humphreys J, Wakerman J, Pashen D. Systematic review of effective retention incentives for health workers in rural and remote areas: towards evidence-based policy. Aust J Rural Health. 2010; 18(3):102-9.^,88 Dolea C, Stormont L, Braichet J. Evaluated strategies to increase attraction and retention of health workers in remote and rural areas. Bull World Health Organ. 2010; 88(5):379-85.^,1616 Wilson N, Couper E, Reid S J, Fish T, Marais BJ. A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. Rural Remote Health. 2009; 9(2):1060..

Long term initiatives include changes in medical graduation and residence with the intent of promoting medical attention in vulnerable areas, especially, family and community physicians. As Australia is one of the countries that suffers the most with the shortage of physicians in remote zones, it has implemented important measures to deal with the problem from the start through the selection of students from rural areas, development of internships and residence in rural areas. Recently Australia has also increased health university campy areas in regions distant from large metropolises.

In Brazil, to increase job oppenings, with priority to the North, Northeast and Center West regions, considered regions with greater shortage of physicians, the Ministry of Education created in 2012 a program turned to the expansion of spaces for medical teaching in Federal Institutions of Higher Education, the IFES and established the goal to create 1,615 new places in existing Medical courses or new courses of Medicine in Federal Universities from 2013 to 2014. In order to create new courses a project was proposed fpr Medical Residence in the same place where the new courses are as means of support for the courses³⁶36 Ministério da Educação. Propostas de expansão de vagas do ensino médico nas Instituições Federais do Ensino Superior elaboradas pelo Grupo de Trabalho instituído pela Portaria n. 86, de 22 de março de 2012. Diário Oficial da União. 27 Mar 2012..

The Federal Government used similar criteria to those of Australia to select municipalities where new medical courses may be opened. Before Law 12,871 (which instituted the Mais Medicos Program) the location of the possible new medicine courses used to be defined with no direction defined by the Brazilian State, so that there was no assurance of internalization of the courses. This way, market determined the distribution of courses, being one of the factors that lead to the iniquity of the distribution of health professionals in the country, even taking into account that new courses should be appreciated by the National Health Council³⁸38 Seixas PH, Corrêa NA, Moraes JC. MigraMed - Migração Médica no Brasil: tendências e motivações [Internet]. São Paulo: Observatório de Recursos Humanos em Saúde de São Paulo; 2014 [acesso 2014 Set 20]. Disponível em: http://www.observatoriorh.org/sites/default/files/webfiles/fulltext/iiienc_migra_uru_dic10/migracao_medica_no_brasil_p.seixas.pdf
http://www.observatoriorh.org/sites/defa... . As it can be observed in Picture 2, most medical graduation courses are located at state capitals and large cities, there being a great correlation between the place of graduation and the place of professional establishment of the physicians³⁹39 Ministério da Educação. Conselho Nacional de Educação. Resolução n. 3, de 20 de junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina e dá outras providências [Internet]. Brasília (DF): 2014 [acesso 2014 Set 20]. Disponível em: http://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?data=23/06/2014&jornal=1&pagina=8&totalArquivos=64
http://pesquisa.in.gov.br/imprensa/jsp/v... .

In 2013, the National Education Council began a joint effort with teaching associations, the National Health Council, the Ministry of Health and others, for the revision of national curriculum guidelines for the medicine courses which, among many measures, assures that 30% of the activities of the internships be developed in primary care services, as well as in urgency/emergency³⁷37 Ministério da Saúde. Resolução n. 407, de 12 de Setembro de 2008. Dispõe sobre as atribuições do Conselho Nacional de Saúde [acesso 2014 Set 20]. Disponível em: http://conselho.saude.gov.br/apresentacao/regimento.htm
http://conselho.saude.gov.br/apresentaca... . Ministries of Health and Education have been acting jointly for the increase of vacancies in medical residence, especially, in general family and community medicine. The Federal, State and Municipal spheres should be linked in order to make it viable that the organization contracts of public actions for teaching in health (COAPES) assure adequate environment for the service teaching integration. Telehealth has been ever more important in broadening public health care in vulnerable areas.

There are many challenges for medium and long-term actions to replace short-term measures. Strengthening the health system depends on an integrated action by all health professionals, it depends on the permanent education processes in defining and developing of general and specific competence turned to the production of health and the integrality of care. These definitions should ground the National Curriculum Guidelines and the construction of a unified graduation evaluation system, approaching institutions which form the health system. The quantitative and qualitative changes in medical training seek to assure not only the universality, but also the integrality and the sustainability of the Brazilian National Health System (SUS).

The success of these initiatives shall depend on the continuity of the federative articulation, the regulatory state policies, as well as of the continuous monitoring and improvement of the program. The potency of the “Mais Medicos” Program, among others, is related to a proposal of change which does not fear looking for new paths, which dialogs to experience, both national and international, and with individuals involved in the broadening of access and quality improvement of primary care and SUS.

Acknowledgments

We thank all SGTES workers that have been contributing in a critical and creative form to produce innovative practices to manage work and health education and who live a unique moment of implanting the Mais Médicos. To the partners from MEC: we thank SESU, INEP and SERES for all the cooperation work in the public compromise for the strengthening of health training integrated to SUS guidelines. Special thanks are due to Alexander Rocha Santos Padilha and Mozart Julio Tabosa Sales's contribution.

References

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