The history of the recent expansion of medical schools in Brazil: a conversation about education, innovation and commitment to the Brazilian National Health System (SUS)

Mara Regina Lemes De Sordi Eliana Goldfarb Cyrino Carolina Siqueira Mendonça About the authors

Keywords:
Medical education; Health education; Social responsability; More Doctors Program; Public policy

Image courtesy of the author.

Henry Campos is a nephrologist with specialization in Medical Education. He is currently the President of Universidade Federal do Ceará (UFC) and has had an important participation, both in Brazil and abroad, as a leader of projects of change in medical education - projects committed to social responsibility, with a greater involvement in public health systems and social needs. He is an enthusiast of innovations in health education and is always on the lookout for possibilities of change. For the last 15 years, he has had an important participation in the Higher Education Department (SESu) of the Brazilian Ministry of Education and Culture, and also in the National Institute for Educational Studies and Research Anísio Teixeira (INEP), heading the System for Validation of Medical Diplomas (known as Revalida). In addition, he has fostered partnership actions between Brazil’s Ministry of Education and Ministry of Health. He is also a member of the National Association of Heads of Federal Higher Education Institutions (ANDIFES) and is aligned with other university presidents in the defense of the Brazilian public university.

We met Henry in an event of the Ministry of Health in 2005 and we met him again in the same year, during the Course for Change Activators(d)(d) Specialization Course in Activation of Change Processes in the Higher Education of Health Professionals, promoted by the Management Department for Work and Education in Health (SGTES) in partnership with the National School of Public Health Sérgio Arouca (ENSP) and with Rede Unida. It was a face-to-face postgraduate course with online support offered by the Distance Education Program of ENSP from May 2005 to July 2006. Fundação Oswaldo Cruz (Fiocruz). Caderno do especializando. Brasília, Rio de Janeiro: Ministério da Saúde (MS), Fiocruz; 2005.], when he was a member of the group that evaluated the course. In 2006, at the end of the Brazilian Medical Education Congress (COBEM), held in the city of Gramado, we met him when we were leaving the event to go to the airport and we had the opportunity of getting to know him a little better. He told us about the State of Ceará, about his pride of being a Northeasterner, the history of the State where he was born, and then he went on to address the subject of a large project he was planning together with teachers from different Brazilian schools: the education of leaders to change medical education in our country.

For the last 12 years, he has coordinated, together with a group of teachers from many higher education institutions, the Brazil-FAIMER Regional Institute for Medical Education. This program has been considered a large collaborative network and a powerful community of practices for teacher education, strengthening changes in education courses in the area of health based on the principles of SUS (Brazilian National Health System) and on pedagogical innovations. On the days that preceded our interview, UFC had held, for the thirtieth consecutive year, Cine Ceará, one of the biggest film festivals of Brazil. Henry was excited about it and told us that the presentation of films had been very special.

The focus of our interview, performed by videoconferencing, was Henry’s work as the coordinator of the Committee for the Monitoring of Medical Schools (CAMEM)(e)(e) Instituted by Directive no. 306 of March 26, 2015, with the purpose of monitoring the implementation and satisfactory offer of undergraduate Medicine programs in federal higher education institutions (known as IFES), together with the Department for the Regulation and Supervision of Higher Education. CAMEM’s objectives are: to participate in evaluation processes of undergraduate Medicine programs in order to assist with regulatory procedures; to conduct evaluation visits in the field at the execution stage of the projects for the implementation of courses in IFES - at least two visits per semester until the act that authorizes the functioning of the new courses is issued; to conduct monitoring visits periodically in the new Medicine courses created in IFES, until the regulatory act of recognition of the courses is issued; to conduct monitoring and evaluation visits in IFES if necessary, according to the demand of the Higher Education policy and its regulatory agencies (http://portal.mec.gov.br/component/content/article?id=59441)., of the Ministry of Education and Culture. We explained to him that the interview is part of the proposal for the publication of a supplement of revista Interface about the education axis of the More Doctors Program.

Please tell us about your role as a medical education leader in Brazil.

In fact, I started to play a more direct role in medical education in Brazil while I was the Dean of the School of Medicine of UFC and I started attending education forums and meetings, but before this I’d been involved in the health area’s struggle... for hospitals, and for the qualification of university hospitals, mainly those of the federal education network. I was a member of the Brazilian Association of University and Educational Hospitals (ABRAHUE). I also developed activities in the Federal Council of Medicine, but my entrance in the world of education really happened in 1999, when I became the Dean of the School of Medicine. In this period, I went to the United States to do a specialization course in medical education in the FAIMER Program, in Philadelphia. When I became the Dean, I thought: “No, this is not for amateurs, I need to professionalize to take this task on”, mainly because one of the challenges we had ahead of us was the curricular change, and this made me get closer to the area, giving me a more comprehensive look... The Brazilian Association of Medical Education (ABEM) and other schools were leading a movement in favor of change and, formally [or finally], it started to take shape, we signed the partnership agreement with FAIMER Philadelphia and installed FAIMER in the city of Fortaleza, where it began to operate in 2007. But, before this, I’d started to do some things for the Management Department for Work and Education in Health (SGTES). When it was created, I used to be called to collaborate, and I also participated in discussions in the Ministry of Health, and all this ended up making me have a constant presence in everything that was related to medical education.

Then a new challenge emerged: the diploma validation issue that we were facing here. Our university received many demands and we considered it a very bureaucratic process that needed to be changed. And then, in a meeting with Fernando Haddad, who was the Minister of Education at the time, which I attended together with the president of UFC, I asked him: “Sir, why don’t we institute a national process in which not only theoretical knowledge, but also practice are evaluated? There is the question of the doctor’s adequacy for SUS; well, I believe we can take a considerable leap, qualifying this process, which can be a form of contribution to our schools that can induce changes”.

And the Minister’s reaction was the beginning of everything: “Do you accept to do this? To do this work? Do you accept it?”

Naturally, the locus to develop this project was SGTES, where we found support and enthusiasm. The work began with Professor Ana Estela Haddad and myself. I already had good knowledge of the process to define the profile for professional practice in the United States and in other countries. We extended the “think tank group”, including Ana Dayse Dorea, who was the President of ANDIFES at the time, and Neile Torres. Our purpose was to construct an isonomic, transparent process, in which the validation candidates would be treated with respect, and which would clearly indicate their aptitude for professional practice.

The next step was to gather a group of specialist doctors. With the decisive participation of Antonio Sansevero and Rui Lima, we refined the conceptual bases of the process and our work culminated in the creation of a matrix of the competencies that the Brazilian undergraduate student should have11 Brasil. Ministério da Educação. Secretaria de Ensino Superior. Ministério da Saúde. Secretaria da Gestão do Trabalho e Educação na Saúde. Matriz de correspondência curricular para fins de revalidação de diplomas de médico obtidos no exterior. Brasília: Ministério da Educação, Ministério da Saúde; 2009., in a subsequent and amplified work that involved a panel in which teachers from 17 medical schools participated.

In the first stage of this work, the teachers defined the competencies of their area and, in a second stage, each one gave their opinion about the others, avoiding that process in which each one wants to highlight their own area. Promoting many rounds to attribute scores to each skill, and using balancing strategies, we progressively reached a consensus regarding the Matrix of Competencies, which would guide the entire validation process. The strongest point of this matrix was that, like similar documents that had just started to be constructed - for example, “Tomorrow’s Doctors” -, it explained, in a clear way, the level of performance expected of each competency: what the undergraduate student needed to have in terms of information, what he’d have to do under supervision, what he’d have to do autonomously, and what he’d have to master, which included situations of imminent risk of death. All this, in short, with great appropriateness and a holistic approach, highlighting the issue of social responsibility, emphasizing the importance of communication skills, and, to use the current language of medical education, stimulating competency-based education.

Thus, we defined an academic trajectory the student should follow to be able to practice Medicine in Brazil, obviously including knowledge of our health system - SUS -, professional practice marked by ethics and compassion, and the commitment to the defense of life. After this matrix was adopted and the subcommittee was appointed, we started to do the exams. These were very deficient in relation to what was expected, which was the issue of isonomy, of having criteria; and Revalida was created in this perspective of innovation, being progressively supported by the society.

In 2013, the mayors’ march took place in Brasília. This event ended up bringing me another mission. Padilha was the Minister of Health, Mercadante was the Minister of Education. The mayors’ main claim in that march was for doctors - there were 750 localities in the country without doctors... without doctors in the surroundings; they formed large unassisted areas. On that occasion, a meeting was held in the Ministry of Education and Culture with the Committee of Medical Education Specialists, and I was invited to attend it.

It was then that the idea of implementing the More Doctors Program emerged. At first, we discussed the coming of doctors from Cuba, which would be followed by a plan to expand the education of doctors in Brazil. We had a study that showed a difference mainly in the distribution of professionals, a concentration we were already familiar with in large urban centers, a very large concentration in Brasília, for example, and something needed to be done, and it was not only a matter of opening new traditional medical schools. The first decision to be made was whether we should bring the Cubans or not, and I became a little embarrassed because Minister Mercadante started assigning duties to me, even though there was the Committee of Specialists. The Minister said: “No, Henry is the one who’ll coordinate the decision-making process”.

Eventually, Mercadante appointed me as Special Assistant for Education Matters in Health Professions. The first clash that occurred, in a certain way, between the Ministry of Education and the Ministry of Health, happened because I defended the opinion that we shouldn’t call the Cubans right away, as seats had been opened in the Qualification Program for Primary Care Professionals (PROVAB) and approximately three thousand Brazilians were left out, as there were no seats for them. On that occasion, I said “I think we should call first the Brazilians that were left out of PROVAB, explaining in which cities the professionals will work, what is the supply that is needed. If the Brazilians do not respond, do not adhere to it, then the coming of professionals from other countries is entirely legitimated”. The expected supply did not occur and a huge work was done, a survey of countries in which these professionals could be recruited, but the offer of Cuban doctors was there, the fastest solution for unassisted areas.

I helped a little in this work, I helped to plan their reception, their training here, but I really invested in what was being done before, to construct a new model of medical school at remote or unassisted places, as the courses could not reproduce the traditional model. We started to define this new model - professors Maria Neile Torres de Araújo, from Universidade Federal do Ceará, Ruy Guilherme Silveira de Souza and Antonio Sansevero, from Universidade Federal de Roraima, and me. Previously, in the Ministry of Education and Culture, when the great expansion of IFES was under way, the universities demanded… every politician wanted a medical school, many new universities were being opened, and I worked initially with Jeanne Michels and then with Adriana Weska, who became head of the Networks Directorate of the IFES. We studied cost projections and the courses’ dimensioning, annual number of seats, numbers of students and servants, all this taking into account geographical and economic references, population data and health indicators. We learned a lot. In a brochure published in the Ministry of Education, we established the guidelines for these new schools, including state-of-the-art elements: commitment to SUS, students’ presence in the community since the beginning of the course, active methodologies, the issue of formative evaluation; in short, everything that points to a process that leads students to construct their own knowledge, to have autonomy and, mainly, to an education based on the local reality, and the school as a whole being oriented by this reality. In this process, the school is born after it was already discussed and articulated with the health system, with a... I’d say... an equal participation of the health network professional and the teacher, breaking a paradigm that exists in Academia, a paradigm that places a difference. The document explains these principles, indicating, to each one of them, a corresponding image and its indicators. It is possible to identify the schools that are fulfilling the goals, the intermediate ones and those which are not doing well.

The need to follow these 38 schools closely, schools that were progressively implemented, led to the creation of CAMEM, whose members were nominated by a Ministerial Directive. A pair of specialists in medical education visited two schools every two months and monitored the evolution of the indicators, registering not only figures and facts, but employing the metaphor used by Professor Francisco Campos: the traffic lights (green, yellow and red). This was like a thermometer that, many times, reduced the interval between visits.

CAMEM was also responsible for the teachers’ pedagogical education process. We even designed a project of 13 teacher education centers for the professionals of the new courses. The Committee worked in a very structured way, complying with guidelines, following an itinerary of visits, monitoring the schools and, indeed, what we saw was the birth of different schools, schools truly oriented to serve in a comprehensive perspective of community-based assistance, conscious of the social determinants of health and using hospitals located within a range of 50 km, having, as their bases, district hospitals, regional hospitals and hospitals that have partnerships with SUS. This model is very distant from the traditional hospital-centric model and creates strong connections with the public health system - SUS.

In addition, we participated in the evaluation of projects to select private schools and tried to apply the same principles to the evaluation for the maintenance of sponsoring institutions, and also to our visits to authorize the schools’ functioning. I can say that we found high-quality projects and, at least in the visits in which I participated, we found good infrastructure conditions and competent teachers.

I think it’s of the utmost importance that the medical schools are monitored and opportunities for teacher development are offered. Instruments that join the Ministry of Education and the Ministry of Health, like the Education-Health Public Action Organizational Contract (COAPES), must be strengthened.

I participated in the conception of COAPES and we saw it as an integrative, powerful instrument, as the city starts to have obligations with the school, mainly with regard to providing accesses to the health network, building units in the rural environment so that students also have training, and, above all, developing a partnership, giving a status of teacher to the network professional, a grant to complement their wages, motivating them to engage in the education process, both in the undergraduate and in the medical residency levels.

In the process of construction of our schools, we also started to claim, based on the example of the Caicó course of Universidade Federal do Rio Grande do Norte (UFRN), that the students of the region should have a bonus in the ENEM-SISu (ENEM = National High School Exam; SISu = Unified Selection System) process, as we know that the professional who stays in the region was born in the region, has bonds with the region. The Caicó school is a fantastic example. Everything was very well articulated and we saw the idea develop in some schools of the State of Minas Gerais, too.

Another thing we defended was a paradigm shift, in that the recruitment of teachers for these schools should majorly occur (mainly in the case of doctors) among local professionals. These professionals are the ones who know the local pathology, know the community, love the community. The school would be committed to guaranteeing education, not only teacher education, but also these professionals’ access to postgraduate courses with incentives for Master’s and doctoral programs, following the example of what we did in Ceará, in 2001, when we initiated the first process of installation of schools outside the main campus in the federal higher education system. We created two schools in Ceará - Sobral and Barbalha -, and the process only started to function for real when we abandoned the idea of requiring that the candidates for the position of teachers should hold doctoral degrees. I used to say to the president, “This doesn’t work, they come, they take the exam and they leave the region. We must value the local professional, we’ll educate them gradually afterwards.” We did it and today, in these two courses, almost 80% of the faculty have titles. Based on this example, we tried to follow this model also in the sphere of the new schools.

I occasionally receive news from these schools and I can say that, in the majority of them, things are moving on, despite the difficulties they face. This represents a seed that will germinate, provided we have, once again, a policy that really supports SUS. Because we’ve been watching a disassembling process. If the Ministry of Health itself does not promote the strengthening, the consolidation of SUS, the support to SUS, how will the Ministry of Education have this as a premise of its movements, in its guidelines? I believe there is an entire field to be recovered and I very much hope we will, indeed, go back to the path we’d started to walk in such a successful way. It was a process guided by social responsibility, all the people involved were committed to it - teachers, students.

We also had memorable moments in the communities that embraced these courses, especially in the public schools that we had the opportunity to monitor. Even in the private courses that were opened, we could induce the principles that must be present in their pedagogical projects and that must be strengthened during the visit for the authorization of functioning. I myself visited many schools and was amazed at what had been prepared and at the articulation that had been constructed with the municipal government, with the health system.

Henry, in fact, you already answered many questions we were going to ask. Sobral and Barbalha are examples of medical schools in an interiorization process that started before this moment. Thus, what was your motivation when you and your colleagues from UFC created Sobral and Barbalha? Perhaps this is a preceding moment of what would happen later. What did you think at that moment? In what year were the courses of Sobral and Barbalha created? Do you think this process influenced your role of coordinator of CAMEM?

The opening of the Medicine courses in Sobral and Barbalha, in 2001, obeyed a logic. These courses were going to be situated in development poles that had a relatively well-established medical community and where there was also local receptivity to the issue of the strengthening of SUS, of Family Medicine, of Family Health - an issue that has always been present in Ceará. I believe we were the precursors of the work with health agents, of the implementation of Family Health teams.

The environment was naturally receptive and when you looked at the surroundings of the cities, you saw there was a shortage of doctors. Thus, an ideal ethos for education initiatives was configured, a place that offered conditions for education and favored the retention of doctors in the region, provided that the process was well-oriented. As we were implementing a new curriculum in the city of Fortaleza, the same curriculum was proposed to Sobral and Barbalha and it already included active methodologies, responsibility for the question of health, of the community, action in different levels, replacement of the hospital-centric model. This really made a difference, because in Fortaleza we had to combat an entire history, an entire structure that was already established. It was much easier to insert the student in the community, it was something totally normal, and I think these examples were really inspiring, they provided an orientation for the model. Of course we went much further and enlarged our horizons. The process started to incorporate other people, other ideas began to emerge, other experiences too; for example, the one in the State of Roraima, which is an innovative course both in terms of methodology and in terms of social responsibility, a course that, although it’s more than twenty years old, functions without having its own hospital. Little by little, other ideas were added, other people gradually arrived and the process was embraced by many people, it became the project of the ministry, of the government, a State project; and this is what I think we’ve lost... We had all the support and all the autonomy to question anyone involved, even the universities’ presidents, about anything that was different from what had been agreed. If, for example, a president did not comply with the construction schedule or used seats of the Medicine course to hire teachers for other courses, he was questioned. We also had very frank conversations with the health secretaries - there was a mandate, so we went there as representatives of the State, as representatives of a State policy. This made a very big difference and this empowerment reached teachers, students and the community. With the defense of the collective dimension, that project became something that belonged to everybody. It wasn’t a school project obtained in a Cabinet, nor among teachers only; rather, it was shared by many people, it had a large participation of students, the presence of the community. It was very rich, very rich indeed.

How did you construct the team that worked with you? How long was CAMEM coordinated by you? How was this Committee created and what are its main marks? What was the relationship between the Committee and the Ministry of Education and Culture? And what were the main challenges it faced?

CAMEM’s work started in 2015, in the second stage of the More Doctors Program22 Brasil. Ministério da Educação. Portaria MEC 306, de 26 de março de 2015. Diário Oficial da União. 27 Mar 2015; sec. 1, p. 39.. The Committee members received an allowance and there was, as I mentioned before, this systematization of work. The significant contribution was that everybody understood the magnitude of the mission, which was followed to the letter. The model we idealized is synthesized in a brochure that circulated internally in the Ministry of Education and Culture. It hasn’t been published yet. In it, all the axes are described, as well as the image corresponding to each point, like articulation with the community, the student’s insertion in the community, evaluation, evaluation quality, use of active methodologies; in short, everything the model establishes that we consider to be the best education process in terms of having a liberating school that educates citizens and defenders of SUS who are well prepared scientifically. CAMEM’s control and monitoring was not only a process, let’s say, of monitoring construction sites, seeing how things were going. We checked if they were hiring personnel, if the classes were being given, we monitored the implementation of the curriculum itself, which was reviewed with teachers and students in a strategy of pedagogical education.

The Committee members were recruited by adherence; the essential aspect was they must have educational background in medical education. Almost all the members of this group came out of the three hundred professionals educated by the FAIMER program. They mastered medical education, they were aware that, to be a good teacher, you need specific education, that you need to be a good manager, too, and that you must have a very strong conviction of the need to change the system, to consolidate SUS, to change the education model, which in fact contributes to perpetuate inequality in care provision.

What were the Committee’s biggest challenges while you coordinated it? What were the most challenging issues?

Although the schools had promised to the Ministry of Education that they would follow the principles of the constructed model, many times, when we arrived there, they had hired the so-called curriculum consultants, which meant a return to the traditional curriculum, whose format would not be fit for the mission. So, it was necessary to provide informed arguments, explaining that the model was inadequate to what was intended, to achieve what had been agreed. We frequently did the exercise of listing the principles and asking the group of teachers to analyze the project with us, questioning: “Do you think this point in the project can correspond to that image? Where were the green, yellow and red lights?” They became aware of what was necessary to change and we gradually built, collectively, the new curriculum, without fragmentation, without separation between basic cycle and clinical cycle. Little by little, things were starting to integrate with each other: the experience in the community and the educational meetings - classes in the form of lectures, group work, Problem-based learning PBL. The challenge was to break with the traditional model, especially in schools that already had traditional Medicine courses, where, frequently, there was pressure to maintain the old curriculum. It was gratifying to see the progressive emergence of great educators, with innovative practices that allowed students to have a holistic view and to give importance to the social determinants of the health-disease process. This was the biggest challenge of the Committee. In the majority of times, it was able to reverse the process and won allies among the teachers, witnessing them grow as educators.

And how do you see the future of these schools? What are the marks of CAMEM in the fight for education, from the very basis you’ve brought from SUS?

CAMEM’s mark in the schools was to develop the educational process in a structured way; the teachers were imbued with this spirit, you know, and they worked in a very integrated way. I believe the work has left followers. Today, we still have a discussion forum, the CAMEM group in WhatsApp, the group of the new schools, and we see that the process continues; in spite of the difficulty they face, they keep following and complying with the same principles.

How do I see the future? I have much hope we’ll have a change in Brazil, a change for the better, with the recovery of a more socially-oriented government that gives more importance to education and health.

This work, this collective construction, has a great chance of being resumed, so that we can see, once again, the blossom of all those education movements with which Brazil became an example to the world. I have much hope this will happen. We are all willing to participate again.

References

  • 1
    Brasil. Ministério da Educação. Secretaria de Ensino Superior. Ministério da Saúde. Secretaria da Gestão do Trabalho e Educação na Saúde. Matriz de correspondência curricular para fins de revalidação de diplomas de médico obtidos no exterior. Brasília: Ministério da Educação, Ministério da Saúde; 2009.
  • 2
    Brasil. Ministério da Educação. Portaria MEC 306, de 26 de março de 2015. Diário Oficial da União. 27 Mar 2015; sec. 1, p. 39.

  • (d)
    Specialization Course in Activation of Change Processes in the Higher Education of Health Professionals, promoted by the Management Department for Work and Education in Health (SGTES) in partnership with the National School of Public Health Sérgio Arouca (ENSP) and with Rede Unida. It was a face-to-face postgraduate course with online support offered by the Distance Education Program of ENSP from May 2005 to July 2006. Fundação Oswaldo Cruz (Fiocruz). Caderno do especializando. Brasília, Rio de Janeiro: Ministério da Saúde (MS), Fiocruz; 2005.]
  • (e)
    Instituted by Directive no. 306 of March 26, 2015, with the purpose of monitoring the implementation and satisfactory offer of undergraduate Medicine programs in federal higher education institutions (known as IFES), together with the Department for the Regulation and Supervision of Higher Education. CAMEM’s objectives are: to participate in evaluation processes of undergraduate Medicine programs in order to assist with regulatory procedures; to conduct evaluation visits in the field at the execution stage of the projects for the implementation of courses in IFES - at least two visits per semester until the act that authorizes the functioning of the new courses is issued; to conduct monitoring visits periodically in the new Medicine courses created in IFES, until the regulatory act of recognition of the courses is issued; to conduct monitoring and evaluation visits in IFES if necessary, according to the demand of the Higher Education policy and its regulatory agencies (http://portal.mec.gov.br/component/content/article?id=59441).

History

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