Development and expansion of medical education in Brazil

Mónica Padilla About the author

With the launch of the More Doctors Program (PMM) by Law no. 12871 of October 22, 201311 Brasil. Presidência da República. Lei nº 12.871, de 22 de outubro de 2013. Institui o Programa Mais Médicos, altera as Leis 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. 23 Out 2013., one of Brazil’s most ambitious policies for the development of human resources in the area of health is put into action. In this culminating moment, the themes of supply, regulation, education and infrastructure of the National Health System (SUS) are joined, with the objective of solving the structural deficit of doctors and meeting the Brazilian citizens’ need of equitable access to healthcare and health services.

Since 2013, the program’s supply component has been designating doctors to provide assistance on a full-time basis, guaranteeing that they live in the localities where they work. The composition of this group of professionals sent to hard-to-reach places, majorly Cubans with experience in primary care, was complemented by professionals who graduated outside Brazil, both Brazilians and foreigners, and by a small but growing percentage of Brazilians who graduated in Brazil (32% in November 2013 - 48% in November 2018(b)(b) In November 2018, there were 16,381 doctors working in PMM. in the service of communities with lower access to healthcare(c)(c) Data obtained from the Project Management System (SGP), Brazil’s Ministry of Health, 2018..

This effective measure, maintained from 2013 to 2018, could provide doctors that complement - and, sometimes, open for the first time - teams in Family Health units at critical regions, thus contributing to efforts initiated in 1998 with the Family Health Program(d)(d) Known, since 2006, as “Family Health Strategy”.. Among the cities that participate in PMM, there has been an increase in primary care coverage, which grew from 77.9% in 2012 to 86.3% in 201522 Santos W, Comes Y, Pereira LL, Costa AM, Merchan-Hamann E, Pacheco Santos LMP. Avaliação do Programa Mais Médicos: relato de experiência. Saude Debate. 2019; 43(120):259-.

Aware of the provisional and emergency nature of the strategy to supply Medicine professionals, the people responsible for PMM implemented measures also in the field of medical education, so that Brazil can achieve self-sufficiency in the number of doctors it needs and can tackle the shortage of this professional, ensuring the sustainability of SUS. To accomplish this, they increased the number of seats in medical schools, implemented obligatory changes in the forms and settings of education in undergraduate programs, and decentralized the offer of courses to remote regions (an important aspect for the subsequent retention of graduates). In addition, they proposed an increase in the offer of medical residencies to ensure that all graduates have access to these programs, and the incorporation of the residency in Family and Community Medicine as a prerequisite for education in specialties with high demand(e)(e) I - Internal Medicine (Medical Clinic); II - Pediatrics; III - Gynecology and Obstetrics; IV - General Surgery; V - Psychiatry; VI - Preventive and Social Medicine..

The hypothesis on which these measures were grounded was that they would build the foundation to guarantee professionals graduated in their communities in sufficient numbers - professionals whose view of health would be coherent with Brazil’s needs, especially with the needs of those populations -, and that their retention would be strengthened through access to the residency in Family and Community Medicine. Likewise, the presence of specialists in distant areas would form the ideal setting to educate new doctors inserted in Brazil’s health reality and, therefore, committed to its demands. Above all, these specialists would significantly improve the quality of a health system based on primary care and organized in networks of health services: SUS.

After the law was promulgated, an important movement was triggered to implement it with a clear formal and legal basis, in a real scenario with multiple obstacles: the positioning of medical associations, the regulation and legal requirements for the creation and management of professional education, which had been basically thought for urban and developed zones, the mental imagery of the population and of potential Brazilian doctors, who focus on the market rather than on public service. In short, a difficult scenario to be faced.

This Supplement of Interface Journal addresses the medical education component developed in PMM in the period from 2014 to 2017. Its aim is to disseminate studies that approached the actions that were developed, as well as advances, achievements, challenges, what we have learned and how we see the future of medical education in the middle and long run.

It is important to stress that this is the first effort to systematize the component of professional education in the area of health generated by PMM in Brazil, as the greatest evidence was generated around the medical supply component.

With this in mind, Interface Journal, commissioned by the Ministry of Health and by the Pan American Health Organization (PAHO), published a Notice on July 21, 2017, inviting researchers, scholars, teachers, students, managers, workers and users of SUS to send articles and experiences about medical education deriving from the changes promoted by PMM(f)(f) Link to submission of documents https://mc04.manuscriptcentral.com/icse-scielo, to be published in a special supplement about “Development and expansion of health education in Brazil”. This supplement aimed to “stimulate the technical-scientific production and the analysis of processes related to health education that emerged with the More Doctors Program, approaching the trajectory and the legacy of the health education policy that was developed”, with the purpose of fostering analyses and debates about recent education policies concerning reorientation of medical education(g)(g) Link to the published Notice https://interface.org.br/chamada-publica-suplemento-especial-sobre-desenvolvimento-e-expansao-do-ensino-em-saude-no-brasil/.

Overall, 42 proposals were submitted, of which twenty articles were published, distributed among the sections “Articles” and “Open Space”. We also included one interview and one debate. We consider this Supplement an extremely valuable publication for those who wish to accompany the process of evolution of medical education in Brazil and we invite you to enjoy this interesting reading.

On the next pages, you will find an important description of a proposal for the reorganization of medical education that gains strength and mobilizes the regulatory and operating structures of the Ministries of Health and Education. It introduces concrete negotiation mechanisms for the use of new spaces of practice, and receives an important adherence of public universities, in its first stage, and of private universities, on its second stage, promoting an increase in the decentralized offer of educational programs and greater equity through the choice of distant regions to install medical schools.

The Supplement shows the effective systematization of Brazil’s efforts in the formulation of policies and programs for the transformation of higher education, confirming the country’s leadership regarding policies targeted at human resources in the area of health in the global level and situating PMM as a mechanism that affects not only laws and regulations, but also academic management processes, where the education profiles of health professionals are defined. The Supplement also presents an in-depth analysis of what is necessary to transform the education paradigm in light of the challenge of maintaining health instead of only responding to disease and death, as well as the limits of fragmented and isolated education (by professions) and contradictions between the appropriation of peculiarities of the Brazilian population and culture and decontextualized technical-scientific education, themes that compose this important compilation and reflection work.

Academic supervision emerges as a demand directly related to the quality of professional education, in the level of investment of the Ministry of Education and in the level of mobilization of the network of public universities and professionals to tackle this need, manifested in different articles of the Supplement. It shows the complexity and importance of educational processes in all their dimensions, even more so if we consider health education as a living process that requires constant transformation as a response to reality.

The challenge of medical residencies is another aspect that the Supplement analyzes very well, both the need to recruit Family Health specialists and the need to establish stable teams in the health services so that it is possible to have a qualified learning and practice setting to accompany professional education in the undergraduate and postgraduate levels. These requirements put higher education institutions in direct contact with managers, mainly municipal managers, reaching the center of the management of SUS.

The article and texts of the “Debates” section provide an interesting analysis from the perspective of the policy’s cycles, the positioning of the social actors and the concrete needs of change and improvement that must be met so that Brazil can respond better to its health and education needs. The texts show that discontinuity in the policies is a factor that decisively affects the consistence, sustainability and quality of the country’s response to its health education challenges.

Important experiences in the treatment of matters like mental health, assistance to elderly citizens and health promotion, related to curricular designs and to efforts for their implementation in compliance with the National Curricular Guidelines (DCN), allow us to identify opportunities and challenges to advance towards the necessary transformation of professional education.

This special volume of Interface gathers, undoubtedly, a select group of scholars committed to the theme of medical education, and enables to identify important advances resulting from the formulation of the More Doctors Law, addressing its limits and difficulties. Furthermore, it shows that medical education is the cornerstone for the effective functioning of SUS and will certainly contribute to define the necessary action so that the Brazilian population can have a better health status.

References

  • 1
    Brasil. Presidência da República. Lei nº 12.871, de 22 de outubro de 2013. Institui o Programa Mais Médicos, altera as Leis 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. 23 Out 2013.
  • 2
    Santos W, Comes Y, Pereira LL, Costa AM, Merchan-Hamann E, Pacheco Santos LMP. Avaliação do Programa Mais Médicos: relato de experiência. Saude Debate. 2019; 43(120):259-

  • (b)
    In November 2018, there were 16,381 doctors working in PMM.
  • (c)
    Data obtained from the Project Management System (SGP), Brazil’s Ministry of Health, 2018.
  • (d)
    Known, since 2006, as “Family Health Strategy”.
  • (e)
    I - Internal Medicine (Medical Clinic); II - Pediatrics; III - Gynecology and Obstetrics; IV - General Surgery; V - Psychiatry; VI - Preventive and Social Medicine.
  • (f)
    Link to submission of documents https://mc04.manuscriptcentral.com/icse-scielo
  • (g)
    Link to the published Notice https://interface.org.br/chamada-publica-suplemento-especial-sobre-desenvolvimento-e-expansao-do-ensino-em-saude-no-brasil/

History

  • Received
    19 Feb 2019
  • Accepted
    07 Mar 2019
UNESP Botucatu - SP - Brazil
E-mail: intface@fmb.unesp.br