We invite researchers, students, professors, managers, workers, and users of the Brazilian National Health System(SUS) to enjoy the present publication, Physician workforce supply within the scope of SUS. This special issue is published by the journal Interface – Comunicação, Saúde, Educação, in partnership with the Department of Planning and Regulation of Healthcare Professional Workforce Supply (DEPREPS), within the Brazilian Ministry of Health, with the support of the Pan-American Health Organization (PAHO). In these pages, readers will find a high-quality and needed sample of knowledge that has been produced on the subject. The public policy created in recent years for physician workforce supply is analyzed from a myriad of perspectives, as never-before seen in other similar works. The policy was developed as a response to the shortage of physicians in remote rural areas and in peripheral urban areas, and the articles included in this issue present the progress achieved by its programs, the obstacles to their implementation, and the challenges that persist.
The aim of the call for papers for this issue was to encourage technical-scientific production about the supply and retention of physicians in vulnerable and hard-to-reach areas of Brazil. Such studies include content such as strategies to strengthen SUS, and analyses and discussions of recent policies such as the Primary Care Professional Valorization Program (Provab) and the More Doctors for Brazil Project.
By the end of the submission period, in May 2016, 122 studies were received. Of these, 24 articles were selected: 18 presented research results, five were experience reports, an interview and a text under the Creation category.
The studies presented in this publication bring life to the scientific production about the formulation process and the technical, social, and political debate and discussion involving one of the greatest health policy interventions ever to be developed by the Brazilian government in favor of SUS: the More Doctors Program.
Accustomed to the great challenges inherent to the monumental size of the country, the Brazilian government has achieved spectacular growth in healthcare coverage, represented by a set of historical milestones. The first includes the health reform provided for in the Federal Constitution, effective in 1988, which presents an ambitious goal for the future: providing the entire Brazilian population with coverage by a public and free unified health system that ensures the right to health.
Brazil has been among the pioneering countries to adopt a comprehensive approach to policies for human resource development in health. This approach has included the creation of the Secretariat for the Management of Health Work and Education (SGETES), a directing unit of maximum institutional authority within the Ministry of Health. This unit works intensely in the field of health education, work, and supply of human resources, with the aim of gradually expanding population coverage and access to services, the main target of government policy.
Over the last decade, a group of nationwide policies have been developed, formalized, funded, and implemented. Based on the concept of territory and population coverage, the Family Health Program established national parameters for forming health teams, thus bringing the idea of progressive expansion to concretion, promoting the right to health.
As occurs at other latitudes, in this current process of expanding healthcare coverage, Brazil has stumbled on concrete limitations. These are associated with the retention of professionals in more remote locations and those with lower rates of development, and lower demand for private market services. These locations are traditionally in the North and Northeast regions.
A series of programs aimed at incentivizing professional retention in these locations have been put into action, especially aimed at physicians. However, professional retention has become a chronic gap in the expansion of coverage gained in the first ten years. In 2012, an analysis of the density of professionals with higher education degrees (physicians, nurses, and midwives) in Brazil showed significant gaps at the national level: 1.8 physicians per thousand inhabitants, with 22 states below the national average and five states with at least one physician per thousand inhabitants11. Ministério da Saúde (BR). Secretaria de Gestão do Trabalho e da Educação na Saúde. Programa mais médicos – dois anos: mais saúde para os brasileiros. Brasília: Ministério da Saúde; 2015..
Special attention has also been given to important programs that promote the expansion of professional education, training professionals to develop profiles more in tune with the needs of SUS. However, even with all the efforts expended to increase the number of trained professionals, the challenge of professional retention persists, since the determining factors of professional retention lie in the features of the health labor market.
Considering the above, the Brazilian government designed and implemented the More Doctors Program (MDP), instituted by Law no. 12.871, of October 22, 2013. This comprehensive policy was based on three legs: emergency supply, medical education, and infrastructure, with short-, medium- and long-term interventions. These actions sought to modify the relationship among social players, challenge governance, and strike a new social balance to respond to the health needs of the Brazilian population, especially in areas with lower rates of development. The aim of the program was to ensure structuring measures to intervene quantitatively and qualitatively in medical education, with the publication of National Curricular Guidelines (DCN) and the reorganization of training physicians and experts for the needs of SUS. This strategy also included creating new undergraduate and medical residency openings. In 2015, the program consisted of 18,240 physicians integrated into family health teams, covering 4,058 municipalities out of a total of 5,55711. Ministério da Saúde (BR). Secretaria de Gestão do Trabalho e da Educação na Saúde. Programa mais médicos – dois anos: mais saúde para os brasileiros. Brasília: Ministério da Saúde; 2015..
This publication reports on the most significant difficulties, debates, and positions that emerged during the process of designing, proposing, debating, and enacting the law that led to the initiation of this ambitious process. Furthermore, it reveals the group of interests, positions, actions, and outcomes of this unprecedented government action.
Four aspects are addressed in this publication: a) the formulation, implementation and/or development of physician workforce supply programs for SUS; b) the impact of the results achieved by physician workforce supply programs on the health of the Brazilian population; c) physician workforce supply programs and actors in the field of health: managers, users, and sectoral entities; and d) an analysis of the different outlooks of the professionals participating in physician workforce supply programs and factors associated with their distribution across the country.
An analysis of the political context is also presented, describing the positions and arguments of social players, who faced with this new policy, have worked towards medical education, work, practices, and relationships that expand access to healthcare services. This represents a significant change in how medical professionals are recruited, hired, and distributed, in the number and types of arenas for medical education, decentralizing professional training in the country. These pages present readers with a clear reading of the interests and positions of the different players involved, based on different and well-employed methodologies, such as the use of public sources of information and social communication, debates, discussions at the level of political decisions, qualitative methodologies, and discourse analysis. The result is an objective presentation of the great challenges facing national dialogue about an already established way of generating health services and delivering care, especially to lower-income populations.
This map of the strategic relationship of Brazilian society clearly shows the imbalance that has been recently implemented, in which the population and inter-federative levels of government advocate for persistent and urgent needs. It also points to a gap in the production and allocation of medical professionals for a part of Brazilian society. The program provides a practical approach and resolution for the issue.
The texts presented here have already been able to characterize the benefits of this choice of policy, which has incorporated figure of physicians into specialized training in family health, led to full-time dedication, and ensured professional retention in 73% of municipalities in the country in 2013. Since then, the positive impacts on health equity and access have been noticeable, confirming that it is possible to incorporate a massively contracted workforce, because of the prior solidity achieved by SUS.
The themes addressed in this issue present the persistent challenges currently in force. These include an analysis of the expansion of medical education opportunities; proposed changes to medical education; the pressure to decentralize the supply of professional education, while still meeting the pre-requisite of quality; the need to change the profile of medical education to meet the needs of the system; the incorporation of perspectives such as interprofessionality; integrating students into medical work early on in their programs; the contradictions of accreditation mechanisms; and the opening of new schools in remote regions.
In sum, this is an exciting work, presenting a wealth of different points of view, and providing readers with a vivacious reading about the public policy that works towards universal health, and the key role of human resources in this trajectory. Without a doubt, this issue will allow readers to be exposed to the reality and challenges of health in Brazil. Thus, we invite you to enjoy this reading and take in the light it shines on actions that contribute to strengthening SUS.
- 1Ministério da Saúde (BR). Secretaria de Gestão do Trabalho e da Educação na Saúde. Programa mais médicos – dois anos: mais saúde para os brasileiros. Brasília: Ministério da Saúde; 2015.
- Publication in this collection