Abstract

Introduction

Throughout its more than 25-year existence, the Brazilian National Health System (SUS) has faced continuous challenges in asserting its constitutional guideline of universal access to health all over the Brazilian territory. Even with the legal landmark created by the 1988 Federal Constitution¹1. Constituição (1988). Constituição da República Federativa do Brasil. Brasília, DF: Senado Federal; 1988., and the subsequent health regulation in the Organic Health Law of 1990, inequalities in the provision of health services lingered between citizens who live in places with infrastructure and specialized manpower available and those who are totally or partially without health care.

During the 1900s, in order to circumvent the severe lack of basic services that afflicts citizens across the country, especially in rural areas and suburbs of large cities, the government bet on the expansion of basic health services by means of financial incentives offered to municipalities that adopted the program, currently called the Family Health Strategy (FHS), which put community health agents, nurses and doctors on the front line. Unlike community health agents and nurses, which showed vigorous growth in numbers in local health systems, physicians ran counter to this expansion, which ended up penalizing regions of greater social vulnerability.

Literature addressing the reasons for this great difficulty in attracting and retaining physicians outside richer and more urbanized places has already pointed to some of the factors that have had the most have an influence on their decision²2. Scheffer M, Coordenador. Demografia Médica no Brasil. São Paulo: Departamento de Medicina Preventiva; Faculdade de Medicina; Universidade de São Paulo, Conselho Regional de Medicina do Estado de São Paulo; Conselho Federal de Medicina; 2015.^–55. Nunes M, Michel J. Iniciativas educacionais relacionadas ao provimento e fixação de médicos no SUS: Graduação e Residência Médica como fatores de fixação de médicos. In: Seminário Nacional sobre Escassez, Provimento e Fixação de Profissionais de Saúde em áreas remotas e de maior vulnerabilidade; 2011; Brasília. Brasília: MS; 2011.. High fiscal instability of municipal budgets and insecure employment contracts, territorial concentration of medical schools and medical residency vacancies, poor working and living conditions for physicians and their families, and professional isolation with lower chances of specializing and progressing in their careers have all contributed to the difficulty of getting physicians to settle and have led to high turnover in some locations, hampering the consolidation of a care model that follows the guidelines proposed by the Ministry of Health for effective and qualified primary care service based on comprehensiveness.

In view of this prolonged care deficit in vulnerable regions, the Ministry of Health has tried to reverse the situation since the 1990s by launching several initiatives to try to attract physicians to the SUS. Some have involved actions aimed at immediately tackling the lack of these professionals, as in the case of the Internalization of the Brazilian National Health System (PISUS) and Internalization of Work in Health (PITS). Others have involved actions aimed at introducing changes in medical education, with long-term effects, as in the case of the Curricular Changes in Medical Courses (Promed) and the National Program for Reorientation of Professional Training in Health (Pro-Saúde). This paper is about an initiative that tried to merge the pillars of provision and training into one program, the Primary Care Professional Valorization Program (Provab); thus showing a new moment of focus on federal government efforts to strengthen primary care at the SUS⁶6. Alessio MM, Sousa MF. Análise da implantação do programa mais médicos. [dissertação]. Brasília: Departamento de Saúde Coletiva, Universidade de Brasília; 2015.^–99. Campos F, Pierantoni C, Machado M. Trabalhadores da Saúde e sua trajetória na Reforma Sanitária. Cad RH Saúde [Internet]. 2006 [citado 25 Fev 2016]; 3(1):13-29. Disponível em: http://scholar.google.com
http://scholar.google.com... .

Provab was launched by the Ministry of Health in 2011 (MH Decree n 2.087) and, since its creation, it has prescribed on-site and distance learning incentives, such as supervision by professional bound to a teaching institution and a family health specialization course promoted by the Open University of the SUS. This initiative bet on reversing professional isolation and strengthening specialties that reinforce the role of physicians in primary care. The National Council of Medical Residency (CNRM) was aware that difficulty recruiting physicians would affect the success of this initiative, so it approved a decree (no. 3/2011) that provided for granting 10% bonuses for those who completed Provab in the selection processes to enter medical residencies. This decree was changed in 2015 (Decree no. 2/2015), to make the bonus exclusively used in residency programs by direct access. This measure was associated with a strategy by the Ministry of Health to encourage the training of specialists in basic and admittedly priority areas for the SUS, or in those with shortages of manpower.

In 2014, when the More Doctors Program (Act no. 12.871/2013) had already been created, the Ministry of Health brought in something new when it allowed cross-migration of participants between programs, as long as they remained in the same municipality. This measure was aimed at not harming the local health systems where professionals had been working. However, the possibility of relocation did not weaken the incentive structures of the programs. In 2015, the selection process for the recruitment of physicians was reshaped with the launch of a unique public notice (no. 2/2015), which began to use the classification “10% mode” for Provab and “no 10% mode” for the More Doctors Program. Another change was the establishment of a oneway transfer from Provab to More Doctors, with the creation of “precedence,” which is priority given to Provab physicians who choose to remain in the municipalities; the positions at hand are no longer offered to potential candidates by public notice. Therefore, if physicians have satisfactorily completed Provab and the requests are validated by municipal administrators, they are automatically reassigned to the More Doctors Program.

Since the Ministry of Health created a direct access path from Provab to More Doctors, the number of physicians who choose to switch modalities and remain longer in primary care has increased. Clearer understanding of the importance of this event is shown by the fact that the number of individuals who decided to extend their experience by means of federal incentives showed more than a fourfold increase between 2014 and 2016. Of the 3,040 physicians who completed Provab in 2014, only 277 decided to migrate. In 2015, this figure went up to 890, although the number of graduates remained stable (3,101). As for 2016, the number of graduates decreased slightly, whereas those who chose to switch to More Doctors reached 55% of the total: they went from 1,245 to 2,247.

Physicians come from a professional class that is often reluctant to accept any government decisions that seem to diminish their professional autonomy or interfere in their labor market. Finding out who these physicians are and their reasons for this apparently unusual behavior may provide clues to understanding the institutional design adopted by the Ministry of Health in the case of Provab and the relationship between this program and More Doctors. This successful “marriage” seems to have depended on the creation of incentives that circumvented medical class opposition while attracting the interest of its members. This paper is about the profile of physicians who are interested in these programs and the way the incentive structure might be affecting their decision to remain longer in primary care.

Method

Secondary data were used, with access granted by the More Doctors Program National Coordination, which is correlated with DEPREPS/SGTES/MS, the entity in charge of making databases available, after a liability note was signed by the applicants. Data were compiled by the Ministry of Health by means of a survey with monitoring purposes.

An electronic survey was sent to all 1,245 participants in Provab 2015 who had requested assignment in the More Doctors Program by means of Public Note no. 02/2016. Of the 1,245 who had access to the survey, 477 completed it. The questionnaire consisted of twenty questions; 16 were closed and four were open. Eleven closed questions addressed the sociodemographic, educational and professional background profiles of physicians. Two closed questions related to their reasons for participating in Provab and migrating to More Doctors; the questions involved listing options by order of priority, scales of and no the neutral option. The remaining three closed questions dealt with the physicians' evaluation of their participation and whether they would recommend Provab; they were not taken into account in this analysis.

With regard to the open questions, respondents were allowed to include comments to explain their reasons for joining Provab, for migrating to the More Doctors Program, and for recommending, or not recommending, this to other physicians. Finally, there was a specific question about suggestions on how to improve the programs. It was not compulsory to the answer the open questions; in a total of 477 questionnaires, the question concerning Provab had 109 comments and the one about More Doctors had 98 comments.

A calculation was made to ensure that the response rate allowed for inferences. The response rate was 38.31% (n=477). This figure represents the studied population, since it reached a minimum threshold for a statistically significant sample (n=300), considering a confidence interval of 95% and a margin of error of 3.62%.

It was also considered important to analyze the possible correlation between the 477 respondents and the universe of 1,245 participants with regard to territorial distribution, according to the eight vulnerability profiles of municipalities defined by the More Doctors Program. This comparison had the purpose of making sure the answers reflected the opinions of physicians who were having completely different experiences, as the ones Provab can provide. Data concerning the 477 physicians revealed that they were allocated in 350 municipalities found in the five Brazilian regions. Municipalities were then fitted in the profile of More Doctors. The result was compared to the distribution of the 1,245 physicians in the same profile, and a strong correlation was observed.

The method used to analyze the quantitative data was descriptive statistics, and the frequency results were presented in charts with the percentages, using the SPSS software for data processing.

With regard to analysis of the qualitative data, the two questions had a total of 207 answers, which were read and categorized in inductive fashion according to motivations that were “pragmatic,” “enthusiastic,” “dedicated” or “idealistic” in nature. These four categories were created on the basis of content analysis of answers, and each answer could be assigned to one or more categories. As for categories, they produced subcategories that were classified according to the tenor of the arguments used to justify the reasons given. In order to explain how the analysis was carried out, the categorization of one of the answers about the reasons for joining Provab in 2015 is shown below:

Table 1 provides a description of the criteria used to include answers in the categories.

For comparative purposes, we used information made available by DEPREPS regarding the profile of physicians who chose to switch to More Doctors after completion of Provab in 2014 and 2015. It is worth noting that this study has limitations regarding its conclusions, because of the secondary nature of quantitative data obtained, the weakness of the instrument used to assess motivation, and the low number of answers to open questions. For this reason, we chose to be very clear regarding the criteria adopted for the analysis of the qualitative data.

Results and discussion

Profile of physicians who completed Provab and migrated to More Doctors in 2016

The analysis of the data revealed that these programs attract mostly young physicians who have not started a family, have recently graduated, and have had little experience and training in primary care, but are eager to learn more about it in practice. Seventy-two percent of the physicians were in their 30s at the time of registration; they were mostly single (69%), and had graduated less than one year ago (61%). Due to their short professional experience, 88% did not have any specialization before Provab, and of the 55% who had worked in primary care before, 62% had done so for only a year or less. These findings suggest that Provab is regarded as an interesting alternative to an initial professional experience, and very often is chosen in order to allow professionals work in or return to their home town after graduation.

Regarding data about the race/color of participants, 41% were Black or Brown. This indicator might seem low compared to the number of Whites, who were the majority (55%) and whose indicator was actually higher than that shown by the IBGE Census of 2010 (48%). However, considering that the high number of Whites in Brazilian university campuses is more common when medical students are taken into account, reaching 74% according to Ristoff¹⁰10. Ristoff D. O novo perfil do campus brasileiro: uma análise do perfil socioeconômico do estudante de graduação. Avaliação Rev da Avaliação da Educ Super [Internet]. 2014; [citado 25 Fev 2016]; 19(3):723–47. Disponível em: http://dx.doi.org/10.1590/S1414-40772014000300010
http://dx.doi.org/10.1590/S1414-40772014... , whereas Blacks and Browns were only 5.6% in 2002¹¹11. Pinto PGHDR. Ação afirmativa, fronteiras raciais e identidades acadêmicas: uma etnografia das cotas para negros na UERJ. In: Feres Júnior J, Zoninsein J, editores. Ação afirmativa e universidade: experiências nacionais comparadas. Brasília: Editora da Universidade de Brasília; 2006. p.136-66., before quotas were introduced, this percentage of 41% of Blacks and Browns is certainly very significant. This high rate in an undergraduate course known to have a profile of White and wealthy students, who usually come from families of physicians, suggests that policies of expansion and countrification of vacancies in medical undergraduate courses and changes in entry requirements, in particular quotas, have allowed for a more diverse socioeconomic background of graduates.

With regard to place of origin, nearly half of the participants were from the Northeast region (48%). This can be explained by the fact that Provab became a work alternative that diversifies the options for professional activity in regions where the availability of medical residency vacancies and job positions is lower in the private sector when compared to the South and Southeast. If this hypothesis seems to be applicable to the South, it must however be put in perspective when it comes to the Southeast, since it is the region that provides the second highest number of participants; 25% were from the Southeast, which is much higher than the percentages found of the Center-West (10%), North (8%), and South (8%).

As for the Northeast, which exceeded the Southeast, this 48% can be attributed to a great extent to a 216% increase in the number of courses, and a 152% increase in the number of undergraduate vacancies in Medicine in public and private higher education institutions between 2000 and 2010, according to data from the Health Graduations Indicator System (SIGRAS)¹²12. Rede Observatório de Recursos Humanos em Saúde. Instituto de Medicina Social. Estação de Trabalho. Sistema de Indicadores das Graduações em Saúde – SIGRAS [Internet]. 2016 [citado 10 Mar 2016]. Disponível em: http://www.obsnetims.org.br/sigras/
http://www.obsnetims.org.br/sigras/... . Likewise, this hypothesis should also be put in perspective, since participants who came from the North accounted for only 8%, and this region had the highest increase in percentage figures between 2000 and 2010, with a significant increase of 375% in the number of courses and a 370% increase in the number of vacancies in medical courses.

One possible explanation for these data is that the place where physicians attend undergraduate courses has an influence on their decision to choose the regions where they will work after they complete the courses, and that the expenses of long-term courses constrain inter-regional migration, although the national merging of selection processes encourages migration. This could explain why the Southeast and the Northeast have more participants, since these regions have the largest absolute number of medical courses, considering both public and private institutions¹²12. Rede Observatório de Recursos Humanos em Saúde. Instituto de Medicina Social. Estação de Trabalho. Sistema de Indicadores das Graduações em Saúde – SIGRAS [Internet]. 2016 [citado 10 Mar 2016]. Disponível em: http://www.obsnetims.org.br/sigras/
http://www.obsnetims.org.br/sigras/... .

Data concerning motivations confirm this hypothesis, since “proximity to the home town” was considered as a “very important” factor by 45% of respondents when they were asked about the reasons for migrating, before “fellowship amount.” As for entering Provab, 36% gave “priority 1” to “municipality location,” which is even more significant, considering that Provab requires physicians to stay for only one year in the chosen municipality, yet physicians considered location to be an important factor in their decision.

Some states in the Northeast and Southeast stand out when place of origin, place of graduation, and workplace are analyzed. Ceará is the state where most participants come from (12%, followed by Minas Gerais with 11%) and where most participants choose to work (12%, followed by Bahia with 10%), whereas Minas Gerais stands out as the state where more physicians complete their undergraduate course (13%, followed by Paraíba with 10%).

The results revealed a picture of Provab graduate students who requested precedence in 2016 that is not dissimilar to the one of the 2,412 physicians who chose the same path in 2014.

The gender indicator shows an equal distribution of women (52%) and men (48%) who requested precedence in 2016; considering the margin of error, aggregate data showed that the percentage of men was 10% lower (45% men, 55% women). However, this difference was mitigated in the group that entered in 2015. In absolute numbers, data from 2014 onward revealed that remaining in More Doctors has attracted more women. However, inferences based on this gender approach must be used with caution. Greater demand could be the result of a larger number of female graduates, as revealed by the trend toward the so-called “feminization” of medicine mentioned by the 2015 Brazilian Medicine Demographics report, which points out that, considering physicians who are 29 years old or younger, women already make up the majority, with 56.2% against 43.8% of men²2. Scheffer M, Coordenador. Demografia Médica no Brasil. São Paulo: Departamento de Medicina Preventiva; Faculdade de Medicina; Universidade de São Paulo, Conselho Regional de Medicina do Estado de São Paulo; Conselho Federal de Medicina; 2015.. These rates are very similar to those found in the 2,412 physicians who requested precedence.

A comparison between aggregate data and that for 2016 only, made on the basis of findings by Medicine Demographics²2. Scheffer M, Coordenador. Demografia Médica no Brasil. São Paulo: Departamento de Medicina Preventiva; Faculdade de Medicina; Universidade de São Paulo, Conselho Regional de Medicina do Estado de São Paulo; Conselho Federal de Medicina; 2015., suggests an increase in the number of male physicians who have shown interest in remaining in More Doctors after completion of Provab. This figure increased between 2014 and 2016: 43.7% of men requested precedence in 2014, 44.8% in 2015 and 48% in 2016, even though the number of female doctors was higher in absolute terms in all editions during the same period. The phenomenon of feminization also affects competitiveness between genders for medical residency vacancies, and it suggests that, as a result of this trend, there may be a relative increase in the number of women who engage in residency. This could lead to a change in the career trajectories of recent male undergraduate students, at least in the short term. In the very competitive setting of the selection process, the 10% bonus granted to participants who have completed Provab is mentioned in both the quantitative and qualitative data as an essential incentive for joining the program. Choice of the More Doctors Program may occur increasingly among physicians who decide to postpone their residencies, as long as the 10% bonus is ensured for future selection processes, along with weekly study hours.

As for data that showed the wide accession of Ceará residents to Provab and their subsequent will to migrate to More Doctors, these variables are reinforced when information about place of origin and graduation and work at Provab is analyzed with regard to all 2,412 physicians. Ceará remains the state with the largest number of participants and the one with the largest number of people working at Provab, considering all editions, in addition to being the first in the number of graduates, with Minas Gerais coming second. This seems to be the result of high growth rates in the number of medical courses and medical course vacancies in the Northeast, but it also reflects high participation of the municipalities in Ceará in the early years of Provab.

Considering age group and time since graduation, out of the 2,412 participants, 78% were under 30 years old and 85% had graduated in medicine after 2012, after Provab was launched; this suggests that these participants learned about the program when they were still studying. This finding, in particular, confirms that the Provab institutional design succeeded in attracting newly graduated medical students by means of selected incentives. But what motivates recent medical school graduates to consider up to seven years of work in primary care, one in Provab and another six in More Doctors?

In the following section, we will discuss the motivations that seem to be behind these choices. Not all decisions are exclusively pragmatic. The 10% bonus granted at the end of Provab has proven to be an incentive to join the program, but it cannot be regarded as an incentive to switch to More Doctors, nor the only reason for doing so. Otherwise, those who complete Provab would have no reason for requesting transfers to More Doctors. However, this is precisely what is happening increasingly. And these figures can still go up, since data from the Ministry of Health show that Provab subscriptions account for an average of 75%. Therefore, this “10% mode” includes a large number of Brazilian physicians.

Motivations of physicians who complete Provab to migrate to More Doctors

In this section, we present the data from closed questions about physicians' motivations to join Provab and migrate to More Doctors:

Although all the items are relevant to the decision to participate in Provab, the 10% bonus for completing the program stands out as the main reason for joining the program, with 74% of priority 1 and 2 altogether. The additional comments made in the open questions confirmed this, since respondents made a point of highlighting the importance of this factor, even if it was already one of the options assessed in the closed question.

The categorization adopted for the analysis of comments showed that, in aggregate, the tenor of motivations was reversed when reasons for joining Provab and migrating to More Doctors were taken into account. When respondents, who were mostly recent graduates, were allowed to comment freely about their reasons for joining Provab, the categories that were more generic and least related to primary care (“pragmatism + dedication”) were mentioned by 62%, whereas the categories that more closely related to primary care (“enthusiasm + idealism”) reached only 39%. The findings confirm this result, since the “possibility of working in primary care” was ranked 4^th as ‘priority 1’ (34%), behind pragmatic reasons, with “10% bonus in residency exams” with 65% of ‘priority 1’. If priorities 1 and 2 are added up, the “fellowship amount” overcomes “possibility of working in primary care” with a 5% margin, whereas it falls behind and is ranked 5^th if we consider ‘priority 1’ only. This is a strong indication that physicians who go straight from college to Provab generally do not do so because of their identification with primary care and/or other SUS fronts, nor has their short experience encouraged them to do so.

Even if fields other than primary care are not losing ground in terms of motivation, interest in primary care gains weight and new color in physicians' motivations to request precedence, by means of both relative increases in categories about which they are concerned and the multiplication and diversity of subcategories: “keep working with PC”, “bonds with the community”, “teamwork”, PC identification”, “qualify care”, “more experience”, and “good relationship with management.” After physicians have experienced Provab for a year, “enthusiasm + idealism” overcomes the other two by a significant 20%. In the questionnaire, “keep working in primary care” accounts for 55% of “very important” motivations, ranking 1^st when compared to the others. Also, “possibility of implementing the intervention project,” accounts for 41% of “very important”. This reveals that identification and commitment to primary care increased among physicians who experienced the program for a year, after experiencing primary care in practice. However, it is important to note that percentages of “enthusiasm + idealism” with regard to More Doctors (60%) did not surpass “pragmatism + dedication,” mentioned initially by physicians as reasons for joining Provab (62%); the 40% for “pragmatism + dedication” of those who requested precedence is also relevant. Chart 2 shows the categories and subcategories.

In order to filter the findings discussed above, a complementary analysis was carried out to see the outcome of categorization if only comments made by the same physicians about reasons for joining Provab and for migrating to More Doctors were considered. Sixty-nine physicians made comments in both questions, which resulted in 122 categories for the first and 127 for the second, which allowed comparison. With regard to Provab, “pragmatism + dedication” accounted for 56% of the comments, whereas “enthusiasm + idealism” accounted for the remaining 44%. The reverse effect is then maximized when it comes to motivations to switch to More Doctors, since “enthusiasm + idealism” accounted for 65% of comments, whereas the other 35% were “pragmatism + dedication”. The same physicians who had given pragmatic reasons for joining kept them, but without the 10%, as a motivation to remain in More Doctors; however, they doubled their enthusiasm for primary care after a one-year experience in Provab.

Conclusions

The typical physician from Provab who remained in More Doctors in 2016 was young, single woman from the Northeast region, who said she was of White or Brown race, and was not from a family of physicians. She joined the program with brief professional experience and saw this new challenge as a means of studying and learning how it actually feels to be a doctor. Provab has a strong training component, and that is how students assimilate it. Participants are not sure about the path they will choose for their hard-earned careers. They do not see the program as a springboard to medical residency, but they experience the contradictions between the booming and financially attractive labor market that requires specialization and the terrible health conditions of a significant part of the population. This requires them to be committed, even in poor working conditions. If incentives are highly necessary to compensate for possible initial expenses, the decision to continue shows signs of commitment and dedication. This is a time when many physicians decide to carry on their projects across the country, very often in order to meet the demands of a population that is forgotten by public policies and overlooked in terms of basic health care.

With regard to incentives provided by Provab, the 10% bonus serves not only as perfect and momentary bait, which it really is, but also serves to foster the development of specialties in areas defined as priority by health policies over the medium and long terms. This happens when the Ministry of Health restricts the use of the bonus to so-called direct-access residencies, which lack specialists. If they have already been granted the 10% bonus to try to engage in medical residency, which is a professional yearning that is widespread among physicians, those who choose to migrate seem willing to postpone it temporarily in favor of More Doctors, or at least until a new, relevant selection process is opened.

The current institutional design of Provab and More Doctors divides them basically into “10% ” and “no 10%” modes, respectively, and it refers to the extra points granted in medical residency exams. Keeping the “10%” and not including them in the design of More Doctors reflects the great institutional, budgetary and political investment the Ministry of Health has been making since 2011 to attract physicians who have recently graduated from Provab and who are key to implementing changes in long-term health policies because of their expected professional flexibility. However, the Ministry of Health does not bet on this profile only to support programs. After all, attracting more experienced physicians who have worked longer in primary care is key to familiarizing them with the idea of becoming supervisors, tutors or preceptors of these programs or others aimed at changing education in medicine on the basis of teaching and service.

Based on the above analysis, we believe that the change implemented by the Ministry of Health in 2014, which was consolidated in the following years and allows for migration of Provab graduates to More Doctors, has made the former an alternative method of access to the latter. By not going through a new selection process, except for validation by municipal administrators, More Doctors does not close the door to young graduates. They can join the program if they wish, since there are no rules for required experience, although it is appreciated. However, deciding to directly join More Doctors and live in unattractive places for many years seems to be very difficult for young university graduates. Therefore, Provab can serve as a gateway.

With a role in mediating the relationship between local management and physicians, the federal government was right on the mark when it built a bridge that leads from Provab to More Doctors and that has significantly reduced the number of vacancies, which is harmful to large numbers of citizens who lack primary care services. Together, these government programs play a key role in tipping the balance in favor of social aspects and in dealing with market demands when they can provide the necessary support to physicians so they do not feel lonely in their paths, which are filled with uncertainties regarding their professional choices.

References

Acknowledgments

We would like to thank DEPREPS, in particular Felipe Proenço de Oliveira, Grasiela Damasceno, Felipe Santos, Sidclei Queiroga, Tiago Storni and Érika Siqueira.

Publication Dates

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