Abstract

Introduction

Several countries have adopted Primary Health Care (PHC) as a strategy to transform the curative, individual and hospital model, instituting a new mindset about health based on a preventive, collective, territorialized and democratic model¹1. Morosini MVGC, Corbo ADA. Modelos de atenção e a saúde da família. Rio de Janeiro: EPSJV, Fiocruz; 2007..

The key attribute of PHC is to act as the gateway to health care in the Brazilian National Health System (SUS), having the role of ensuring attention to most health needs, while filtering access to other levels of care. It is required that the family health unit (main strategy of PHC in Brazil) should be accessible to the enrolled population, eliminating financial, geographical, temporal and cultural barriers; aspects usually covered by the Family Health Strategy (FHS)²2. Escorel S, Giovanella L, Mendonça MHM, Senna MCM. O Programa de Saúde da Família e a construção de um novo modelo para a atenção básica no Brasil. Rev Panam Salud Publica. 2007; 21(2):164-76..

The responsibility for PHC was left to the municipal manager within the process of creating the SUS therefore defining municipalization as a political and administrative strategy, with the purpose to decentralize health services. The Basic Operating Guideline (NOB) SUS 01/93³3. Brasil. Ministério da Saúde. Conselho Nacional de Saúde. Norma Operacional Básica nº 1, de 1996. Norma Operacional Básica do Sistema Único de Saúde - Sus. Diário Oficial da União [Internet]. 6 Nov 1996 [citado 3 Abr 2016]. Disponível em: http://conselho.saude.gov.br/legislacao/nobsus96.htm
http://conselho.saude.gov.br/legislacao/... is the way by which the Ministry of Health disciplines the process of decentralization for the construction of SUS, understanding decentralization as: process of redistribution of power; redefinition of roles and construction of new relationships between the three spheres of government; institutional reorganization; as well as control by the society, with the ultimate goal of the complete reformulation of the care model. These processes are seen as an articulation and municipal mobilization that takes into account the characteristics and profile of each municipality, be they geographic, epidemiological, demand and service offer.

It was at NOB 01/93 that “the municipality was explicitly defined as the specific manager of the services and the different levels of SUS adherence were established, as well as the responsibilities and forms of transfer of resources that correspond to them”⁴4. Arretche M, Marques E. Municipalização da saúde no Brasil: diferenças regionais, poder do voto e estratégias de governo. Cienc Saude Colet. 2002; 7(3):455-79..

A study regarding municipalization in the state of Santa Catarina showed that in the process of decentralization based on municipalization, there is also a strong concentration of power by the states and the Union, anchored in the financial resources’ control. As rule changes happen systematically, they put municipalities in the place of enforcers of rules that come already decided. Additionally, whenever municipalities adjust to comply with a rule established by the Ministry of Health, new changes appear soon thereafter, causing “efforts towards municipal autonomy to consolidate very slowly”⁵5. Ortiga AMB, Conill LM. Municipalização da saúde: a trajetória no estado de Santa Catarina. Rev Saude Publica. 2009; 1(1):27-35. (p. 33).

Brazilian health institutions have historically experienced great difficulties. The problems related to the field of Work Management and Health Education are identified as one of the main factors that lead to de-skilling of health services⁶6. Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Gestão do trabalho e da regulação profissional em saúde agenda positiva do Departamento de Gestão e da Regulação do Trabalho em Saúde. Brasília, DF: SGTES; 2005..

Resolution No. 330 of November 2003 issued by the National Health Council defined the application of the Principles and Guidelines for the Basic Operational Standard for Human Resources for SUS (NOB/RH SUS) as the National Policy for the Management of Work and Education in Health. Although work management (WM) has been previously identified as key for the consolidation of SUS, until now it has not received due attention, commensurate with the degree of importance it represents for the health system⁷7. Brasil. Ministério da Saúde. Conselho Nacional de Saúde. Princípios e diretrizes para a gestão do trabalho no SUS (NOB/RH-SUS). 3a ed. Brasília, DF: CNS; 2005..

The Management of Work and Education in health has been described as one of the main challenges for consolidating the SUS⁸8. Brasil. Conselho Nacional de Secretários de Saúde. A gestão do trabalho e da educação na saúde. Brasília, DF: CONASS; 2011.. This is related to the fact that Management and Regulation of Work need to face the problems of shortage of professionals, precariousness in work relationships, inadequate professional profiles to work in SUS and the lack of commitment of parts of professionals to public health⁹9. Pinto ICM, Teixeira CF. Formulação da política de gestão do trabalho e educação na saúde: o caso da Secretaria Estadual de Saúde da Bahia, Brasil, 2007-2008. Cad Saude Publica. 2011; 27(9):1777-88. .

The issue regarding the supply of professionals from different areas in public health is even prior to the creation of the SUS¹⁰10. Silva NCR, Raquel BR, Thiago AH, Rodrigues Junia M. Gestão de recursos humanos em saúde e sua necessária interface ao mundo organizacional – um olhar ampliado. In: Anais do 33o Encontro da ANPAD; 2009; São Paulo. São Paulo: ANPAD;2009., but when it comes to the lack of medical professionals, the problems become even more difficult to overcome.

As a way of pressure for the Federal Government to help the municipalities in the hardships in providing doctors, in February 2013 mayors of several municipalities launched an electronic petition entitled “What happened with the doctor?”. This petition demanded the federal government to urgently hire doctors trained abroad to work in PHC, with the purpose of helping municipalities to overcome the shortage of doctors in regions with difficulties in providing and retaining these professionals¹¹11. Carvalho MS, Sousa MF. Como o Brasil tem enfrentado o tema provimento de médicos? Interface (Botucatu). 2013; 17(47):913-26..

In order to overcome these bottlenecks, it was issued a Provisional Measure (MP) No. 621/2013, instituting the More Doctors Program (PMM), later becoming Law No. 12,871 / 2013, as part of the Pact for Health. In the PMM it is foreseen the Mais Médicos para o Brasil Project (PMMB) with the aim to provide medical professionals in the regions with difficulty in accessing and settlement of this type of practitioner. The latter is responsible for the allocation of approximately 14 thousand doctors in several municipalities in the country¹²12. Brasil. Ministério da Saúde. 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. 22 Out 2013.,¹³13. Santos LMP, Costa AM, Girardi SN. Programa Mais Médicos: uma ação efetiva para reduzir iniquidades em saúde. Cienc Saude Colet. 2015; 20(11):3547-52..

The coordination of the PMMB done jointly by the Ministries of Health and Education, which are responsible for: ordering the participation of higher education institutions in the project; as well as the rules of participation inherent in the work management of the participating physician; namely: workload, chances of leave and recess¹²12. Brasil. Ministério da Saúde. 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. 22 Out 2013..

Despite the continuous growth in the number of doctors in the country for 40 years, and Brazil having as of 2012 a 557.72% jump in the number of these professionals, starting from a distribution of about 1.5 doctors for each group of 1,000 inhabitants in 1980, to about 2.0 doctors for every 1,000 inhabitants in 2012, the country is still among the countries with the worst distribution of these professionals in the doctor/population ratio¹⁴14. Conselho Federal de Medicina. Demografia Médica no Brasil, São Paulo: CREMESP, CFM, 2013. v. 2..

In the scope of the insufficiency of doctors per inhabitants in Primary Care, most of the most deprived municipalities of these professionals are located in the Northeast Region (663 or 51.8%), with a resident population in these places corresponding to 49.3% of the resident population in doctors’ shortage areas¹⁵15. Girardi SN, Carvalho CL, Araújo JF, Farah JM, Wan der Maas L, Campos LA. 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.. Pernambuco ranks third among the states that received more doctors by the PMMB in the first five cycles of the project, through the allocation of roughly 14% of professionals in the Northeast Region¹⁶16. Nogueira PTA, Bezerra AFB, Leite AFB, Sousa IMC, Gonçalves RS, Silva KSB. Características da distribuição de profissionais do Programa Mais Médicos nos estados do Nordeste, Brasil. Cienc Saude Colet. 2016; 21(9):2983-92..

Considering that the work management in SUS is historically configured as a critical crossroad for the effective guarantee of health as a social right to all Brazilians, especially the problem of supply of medical professionals, and that the PMM is characterized as a program that proposes to overcome this difficulty; the present article aims to understand the meanings that municipal managers give to the PMM in terms of work management, autonomy of municipal management and the relationship between the federal entities in the management of the program.

Methodology

This article reports the results of a study using a qualitative approach, geared towards understanding the meanings that managers give to the PMM regarding work management. It is the result of the master’s thesis entitled “Mais Médicos Program from the perspective of municipal managers in the state of Pernambuco”.

The use of qualitative research was deemed as the most appropriate approach to achieve the objectives of this article because it is a method that aims to approach the world and understand, describe and explain social phenomena, through the analysis of the experience of individuals or groups, examining interactions and communication that are developing as well as by investigating documents or similar traits of experiences or interactions, which is based on human perception and understanding¹⁷17. Flick U. Desenho da pesquisa qualitativa. Porto Alegre: Artmed; 2009.,¹⁸18. Stake RE. Pesquisa qualitativa: estudando como as coisas funcionam. Porto Alegre: Penso; 2011..

The subjects of this study were the municipal managers of Pernambuco who are part of the executive board of the Council of Municipal Secretaries of Health of Pernambuco (COSEMS / PE), who were acting in the municipal management at the time of implantation and/or implementation of the Mais Médicos Project for Brazil between August 2013 and December 2016, and also received medical professionals from the project. The whole board is composed of 5 managers, of whom, 4 fit the inclusion criteria of the research.

Five interviews were performed but one interview was discarded due to the non-compliance with the eligibility criteria of one of the interviewees. To guarantee the confidentiality of the survey’s informants, the identification of the interviewees was made using the name of birds named in the songs of the king of baião (popular rhythm of the Brazilian Northeast) Luiz Gonzaga, in the following order: Interview 1 - Asa Branca, Interview 2 - Assum Preto, Interview 3 - Sabiá and Interview 4 - Acauã.

The present study adopted an open interview, in order to understand the opinion, knowledge and experience¹⁹19. Pope C, Mays N. Pesquisa qualitativa na atenção à saúde. Fajardo AP, tradutor. 2a ed. Porto Alegre: Artmed; 2005. of managers regarding the supply of medical professionals, based on the PMM. The guiding provocation used was: Please, tell us about Work Management in the Mais Médicos Program in your municipality. After getting the data from the guiding question, other questions emerged and new questions were asked to address the emerging themes and answer the study’s objectives. The interviews were examined through content analysis.

The data from the interviews were organized into groups of meanings, separated by themes, from which the following categories emerged: the dynamics of municipal management in the PMM: from allowances to innovation; from mission accomplishment to popular acceptance; the importance of the PMM for strengthening municipal management; the dialogue between PMM actors: from support to submission (Frame 1).

This paper is an integral part of the project “Innovative initiatives in the organization of healthcare networks and regions and its impact on the structuring of sus supply: an evaluative study”, funded by CNPq, approved by the Call MCTI/CNPq/CT-Saúde/MS/SCTIE/Decit No. 41/2013 - National Health Policy Research Network: Knowledge for the effective Universal Right to Health.

According to CNS Resolution No. 466, of December 12, 2012, the research was approved by the Ethics and Research Committee CEP / CCS / UFPE, No. 674,336.

Results and discussion

The results and the discussion will be presented by themes in the categories that emerged from the analysis made by the authors, following the order described in TABLE 1.

The dynamics of municipal management in PMM: from allowances to innovation

The reality of shortage of resources, jointly with the dependence on resources transferred by other spheres of government, is an usual cause of exposure of the municipal management to a subordinated position to the policies and programs defined by the Ministry of Health and state secretariats, which present a mostly centralized character. This is observed in the issuing of regulations that the municipalities must implement, under penalty of losing the financial and/or subsidized material coverage, if the execution does not follow the pre-established regulations; this happens even when they do not correspond to the reality of such municipalities.

Concerning the role of the municipal manager in the management of work in the PMM, the managers highlighted the administrative and bureaucratic function as their main obligation of municipal management in the Program. According to Asa Branca, “the support given by the municipality is bound by the infrastructure for the professional until he joins the team. It ends up being an administrative responsibility”.

Following the Inter-ministerial Ordinance No. 1,369 / 13, the municipalities and the Federal District are responsible for: to act in cooperation with the federal entities, Higher Education Institutions (HEI) and international organizations; to insert doctors in primary care teams in the modalities provided for in the National Primary Care Policy (PNAB); to monitor and supervise the execution of teaching-service activities; to meet the doctor at the airport guaranteeing housing, food, drinking water and conditions to carry out the physician’s professional practice, in addition to adhering to the Basic Health Units Reform Program²¹21. Brasil. Ministério da Saúde. Ministério da Educação. Portaria Interministerial nº 1369, de 8 de Julho de 2013. Dispõe sobre a implementação do Projeto Mais Médicos para o Brasil. Brasília: Ministério da Saúde, Ministério da Educação; 2013.,²²22. Brasil. Ministério da Saúde. Informe nº 6: documento de orientação para as Comissões de Coordenação Estadual. Brasília: Ministério da Saúde; 2013..

It was also highlighted that the physicians coming from the PMM should be part of the family health teams like any other professional in the municipality, being included in the policies that the municipality offers, within the scope of work and education management. Acauã pointed out that “the support given to the PMM doctor is the same to the support given to professionals who are not from Mais Médicos, not different from the policies that the municipality already has in place”.

The Brazilian Health Reform, as a social reform project, achieved as its outcome a partial reform, with sectorial and institutional predominance, identified in the construction of the Unified Health System. As a consequence of this there has been a historical difficulty in health financing, causing that management autonomy at the municipal level is directly linked to the need for decentralization of resources⁵5. Ortiga AMB, Conill LM. Municipalização da saúde: a trajetória no estado de Santa Catarina. Rev Saude Publica. 2009; 1(1):27-35.,²³23. Paim JS. Reforma sanitária Brasileira: contribuição para a compreensão e crítica. Salvador, Rio de Janeiro: EDUFBA, Fiocruz; 2008..

A study with municipal managers in Minas Gerais, found that 68.9% of municipal managers perceive low autonomy regarding resource management. Sixty percent (60%) of them stated that state and federal resources are not enough for the implementation and functioning of Family Health Strategy²⁴24. Junqueira TS, Cotta RMM, Gomes RC, Silveira SFR, Siqueira-Batista R, Pinheiro TMM, et al. As relações laborais no âmbito da municipalização da gestão em saúde e os dilemas da relação expansão/precarização do trabalho no contexto do SUS. Cad Saude Publica. 2010; 26(5):918-28..

Within the PMM the prerogatives under the responsibility of the municipalities do not escape the centralized form of programmatic building, evident in the discourse of the managers, as they place under the main responsibility of the municipality to comply with the administrative regulations of the program.

However, the fact that the provision of doctors is financed by the Ministry of Health allowed the municipalities to think about new forms of work management, as the concern shifted from thinking about how to guarantee doctors in the units, towards thinking about the insertion of doctors from the PMM in the Primary Care network of their municipalities. These data concurs with the findings of Souza²⁵25. Souza BPA. Projeto Mais Médicos para o Brasil: uma avaliação da fixação dos profissionais e dos efeitos no acesso à Atenção Primária à Saúde [Dissertação]. Recife: Instituto Aggeu Magalhães; 2018. who identified that if there were no interventions by the federal government to assist in the supply of doctors, the expansion of PHC assistance coverage would not be possible only based on the efforts of the municipalities.

For Assum Preto,

To think about work management as an axis of the organizational structure of health services means thinking strategically, since the productivity and quality of the service offered to society will reflect the form and conditions with which those who work professionally in the organization are treated²⁶26. Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Cadernos RH Saúde. Brasília: Ministério da Saúde; 2006. v. 3..

Another aspect perceived in the speeches of the interviewed managers was the innovation in the management of work and education in the municipalities. Sabiá shared that “management constituted a nucleus that provided all support regarding language, to the discussion of clinical cases, the discussion of the network, their insertion in the network”. These aspects showed the option made by management to overcome purely administrative tasks, creating a structure to provide conditions for professionals to perform their functions, in a more technically instrumentalized way.

In the realm of health, education occupies a strategic place, considering that the challenges to change in the training of workers have as a background the process of implantation and consolidation of SUS and its policy of reorienting actions and services. This happens through the strengthening of the Family Health Strategy and its commitment to the provision of universal, comprehensive, equitable, continuous and, above all, giving resolutive assistance to the population²⁷27. Costa RKS, Miranda FAN. Formação profissional no SUS: oportunidades de mudanças na perspectiva da estratégia de saúde da família. Trab Educ Saude. 2008; 6(3):503-18..

The institution of a permanent education core group in the municipality to support the PMM professional suggests the potent character of the program, insofar as it provided innovations in work management and health education.

Findings from this study suggest that the articulation between teaching and service, enhanced by the program, is an important tool for transforming work management and health education, allowing transformations in the work process within health services and consequent changes in the care provided the population.

The program enabled municipalities to rethink the physicians’ work process in the Family Health Strategy. According to Sabiá:

Incorporating permanent education as a strategy to overcome the teaching-service dichotomy is a powerful device for changing the model of care and health care for the population¹¹11. Carvalho MS, Sousa MF. Como o Brasil tem enfrentado o tema provimento de médicos? Interface (Botucatu). 2013; 17(47):913-26..

From achieving the mission to popular acceptance

The PMM public call allowed the participation of Brazilian doctors trained in Brazil, Brazilian doctors trained abroad and foreign doctors. To this end, international cooperation was established between Brazil, Cuba and the Pan American Health Organization (PAHO). As a result, until 2015, around eleven thousand Cuban doctors were incorporated in health teams in the PHC network throughout the country¹²12. Brasil. Ministério da Saúde. 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. 22 Out 2013.,²⁸28. Terra LSV, Fabiano TB, Lidola M, Hernández SS, Millán JIM, Campos GWS. Análise da experiência de médicos cubanos numa metrópole brasileira segundo o Método Paideia. Cienc Saude Colet. 2016; 21(9):2825-36..

As of December 2015, 4716 doctors from the PMM were allocated in the Northeast. Of them, 3735 doctors came through the international cooperation Brazil-Cuba-PAHO, and as a result about 80% of the doctors allocated in the Northeast, by the PMMB, were Cuban doctors¹⁶16. Nogueira PTA, Bezerra AFB, Leite AFB, Sousa IMC, Gonçalves RS, Silva KSB. Características da distribuição de profissionais do Programa Mais Médicos nos estados do Nordeste, Brasil. Cienc Saude Colet. 2016; 21(9):2983-92..

During the interviews, the managers highlighted that the Cuban doctors allocated in their municipalities, were expressing the differences between the Cuban doctor and the Brazilian doctor, as in Asa Branca’s words: “they came with the mission to effectively work and serve the population; and they did! This is different from the Brazilian doctors, who always had difficulties in fulfilling their workload”.

The grievance regarding non-compliance with the workload by Brazilian doctors was also present in the speech of other interviewees such as Assum Preto, who stated that this is one of the main problems of the program brought to the attention of the Pernambuco State Coordination Commission (CCE-PE) by all municipalities.

The problems with the compliance with the workload by Brazilian physicians have already been pointed out by municipal managers as responsible for the turnover of this type of professional in Primary Care services²⁴24. Junqueira TS, Cotta RMM, Gomes RC, Silveira SFR, Siqueira-Batista R, Pinheiro TMM, et al. As relações laborais no âmbito da municipalização da gestão em saúde e os dilemas da relação expansão/precarização do trabalho no contexto do SUS. Cad Saude Publica. 2010; 26(5):918-28..

The relationship between the reduction in HFS coverage associated with increased access (number of consultations, diagnoses, hospitalization and referrals) suggests that doctors allocated to the HFS prior to the PMMB did not attend fulltime at the HFS, as Cuban doctors in the Program did²⁹29. Silva BP, Stockmann D, Lúcio DS, Henna E, Rocha MCP, Junqueira FM. Ampliação do acesso à saúde na região mais vulnerável do estado de São Paulo, Brasil: reflexo do Programa Mais Médicos? Cienc Saude Colet. 2016; 21(9):2899-906..

The quality of the cooperative physician’s work was also highlighted, as noted by Assum Preto:

These findings concur with those of Santos et al.¹³13. Santos LMP, Costa AM, Girardi SN. Programa Mais Médicos: uma ação efetiva para reduzir iniquidades em saúde. Cienc Saude Colet. 2015; 20(11):3547-52., in the interviews with managers and health professionals from poor municipalities in five regions of the country, reporting that refer to the integration of the Cuban medical professional participating in the PMM as responsible for expanding the diagnostic capacity of problems in the territory. The authors affirm that Cuban doctors accomplished more agility and continuity in the treatment of the user, adding new experiences and care practices, contributing to the improvement of PHC, in addition to permanent support towards the organization of services and teamwork.

A study on the implementation of the PMM, with professionals from other categories working with the program’s physicians, revealed the existence of good interpersonal and professional relationship between the doctor, the team and the users. The emphasis is placed on understanding, partnership and friendship as factors that contribute to the bond with the team and community³⁰30. Comes Y, Trindade JS, Pessoa VM, Barreto ICHC, Shimizu HE, Dewes D, et al. A implementação do Programa Mais Médicos e a integralidade nas práticas da Estratégia Saúde da Família. Cienc Saude Colet. 2016; 21(9):2729-38..

Cuban doctors’ work has already been the subject of research analysis across the country, pointing out users’ satisfaction with their work³¹31. Brito LM. Programa Mais Médicos: satisfação dos usuários das unidades básicas de saúde de Ceilândia/DF quanto ao atendimento médico [monografia]. Brasília: Faculdade de Ceilândia, Universidade de Brasília; 2014.,³²32. Santos LX. Integralidade do cuidado praticado pelos cubanos do Programa Mais Médicos para o Brasil: a percepção dos usuários [dissertação]. Recife: Universidade Federal de Pernambuco; 2015.. It was observed in the present study that the managers’ report indicate that the way Cubans relate and provide care to users made the users of health services to accept them in a very positive way. As noted in Sabiá’s comment:

These results corroborate findings of the study that interviewed users seen by Cuban doctors in the municipality of Mossoró (Rio Grande do Norte), in which the authors understood that users feel welcomed and encouraged to actively participate in medical consultations, additionally feeling satisfied, praising the doctor’s attitudes, such as looking straight at the face and giving opportunities to speak out³³33. Silva TRB, Silva JV, Pontes AGV, Cunha ATR. Percepção de usuários sobre o Programa Mais Médicos no município de Mossoró, Brasil. Cienc Saude Colet. 2016; 21(9):2861-9..

Researching the experience of Cuban doctors, it was identified that doctors who came from Cuba’s mission to Brazil have at least one specialization in General Comprehensive Medicine (MGI in the Portuguese acronym); experience in other international missions, such as those in Haiti and Venezuela; and were motivated by the desire to help countries that need support²⁸28. Terra LSV, Fabiano TB, Lidola M, Hernández SS, Millán JIM, Campos GWS. Análise da experiência de médicos cubanos numa metrópole brasileira segundo o Método Paideia. Cienc Saude Colet. 2016; 21(9):2825-36.. This suggests that the acceptance received by Cuban doctors is related to the quality of the assistance provided by these professionals and the establishment of social and care relations guided by the principle of solidarity between peoples.

Research carried out with Cuban doctors in order to investigate the motivation to come on a mission to Brazil, identified that they refer the desire to obtain more experience, greater qualification, to help countries with difficulties and, above all, that there is no financial relationship for their coming. They emphasize that are fully motivated to offer the best care to the population, focused on learning and are not concerned with anything else than transmitting their knowledge to practical actions in order to improve the population’s health³⁴34. Medeiros ES. A motivação de médicos cubanos em uma política pública brasileira: a xenofobia e interferência na qualidade dos serviços. In: Anais do 11o Simpósio de Excelência em Gestão e Tecnologia; 2014; Rio de Janeiro. Rio de Janeiro: Seget; 2014..

The importance of PMM for strengthening municipal management

The managers interviewed at Cosems / PE referred to the PMM with compliments. Assum Preto remarked: “the program gave autonomy to the municipality, it valued the manager’s person”. The manager pointed out that the relationship with the Cubans provided “capacity to take the PMM as an example to negotiate with other doctors”. He also noted that with the supply of doctors provided by the PMM there are “people who forget the absence of professionals because they have the program, but if the program ceases to exist, it is complicated”.

With the end of the Brazil / Cuba cooperation, the country has gone backwards in the advances provided by the PMM. There is frequent news about the difficulty of guaranteeing doctors for areas that were left without a doctor after Cubans left the country. This has threatened what Sabiá pointed out as an advance:

Research regarding the PMM in Mato Grosso concluded that, even in the controversial and unfavorable to popular forces political scenario, the greater access to health promoted by the program was undeniable, especially in vulnerable municipalities and regions. This allowed the expansion of the set of social and political rights of individuals and collectivities³⁵35. Mota RG, Barros NF. O Programa Mais Médicos no Estado de Mato Grosso, Brasil: uma análise de implementação. Cienc Saude Colet. 2016; 21(9):2879-88..

Comes et al.³⁰30. Comes Y, Trindade JS, Pessoa VM, Barreto ICHC, Shimizu HE, Dewes D, et al. A implementação do Programa Mais Médicos e a integralidade nas práticas da Estratégia Saúde da Família. Cienc Saude Colet. 2016; 21(9):2729-38., concluded in a study regarding the implementation of the PMM from the perspective of the members of the Family Health teams who received doctors from the project, that the Mais Médicos Program contributed to the presence of comprehensiveness features in practices, positively impacting the improvement of primary health care.

The dialogue between PMM actors: from support to submission

CCE-PE has the mission of supporting the municipalities and discussing the PMM’s prerogatives. It was created as an instance of coordination, guidance and execution of the activities necessary for the execution of the PMM within the scope of the State; it has representation from the Ministry of Health, the State Health Secretariat, COSEMS and the higher education institutions that are part of the PMM²¹21. Brasil. Ministério da Saúde. Ministério da Educação. Portaria Interministerial nº 1369, de 8 de Julho de 2013. Dispõe sobre a implementação do Projeto Mais Médicos para o Brasil. Brasília: Ministério da Saúde, Ministério da Educação; 2013.. This instance allows that the three federated entities are able to discuss the program at the state level.

When referring to the relationship of the municipal management with actors from other federated entities in the PMM, the managers declare to have a calm relationship both with the supervisors (linked to the higher education institutions), and with the components of the CCE, as pointed out by Asa Branca “it is very true that we have a good relationship with the supervisors belonging to the state level commission ”.

A study on the Program for Valuing Primary Care Professionals (PROVAB), show that supervision, from the perspective of supporting teams and in a multidisciplinary way in the principles of permanent education, recognizing and cooperating with SUS workers, is an important factor changing health practices and care¹¹11. Carvalho MS, Sousa MF. Como o Brasil tem enfrentado o tema provimento de médicos? Interface (Botucatu). 2013; 17(47):913-26..

Research done in Minas Gerais identified that just 24.4% of municipal managers had some level of articulation with higher education institutions (universities) in the process of structuring the health network in their municipalities²⁴24. Junqueira TS, Cotta RMM, Gomes RC, Silveira SFR, Siqueira-Batista R, Pinheiro TMM, et al. As relações laborais no âmbito da municipalização da gestão em saúde e os dilemas da relação expansão/precarização do trabalho no contexto do SUS. Cad Saude Publica. 2010; 26(5):918-28..

The PMM made it possible to bring the academy closer to municipal administrations, enabling an integrated discussion of the problems of acting in health. For Assum Preto, “there is the supervision of university professionals. We don’t work alone, we have the support of training institutions”.

Notwithstanding, even with the support given by CCE in the discussion of the operationalization of the program; despite the support given by higher education institutions in training professionals in line with the needs and reality of PHC, it is still observed that municipal management is not seen as an actor integrated in all processes in the construction of health and in facing daily challenges.

Asa Branca in her report suggests an important challenge for building the Mais Médicos Program, insofar as there is an emergent contradiction of being a program to assist municipal management but “overriding” it in some decision-making processes.

Asa Branca pointed out that “there were situations passed directly to the commission (...) by the practitioners, and we only learned about this whole evaluation because someone from the (state) commission sent it to the municipality”.

A research regarding the difficulty of providing doctors highlighted the definition of the regulatory framework for the management of work and education for the country as a key challenge to be discussed in a propositional agenda in this thematic field¹¹11. Carvalho MS, Sousa MF. Como o Brasil tem enfrentado o tema provimento de médicos? Interface (Botucatu). 2013; 17(47):913-26..

Final considerations

Although the study identified that there is still a gap between the municipal management, the other federated entities and the training institutions in the decision-making process within the Mais Médicos Program, it was found that the program was an important inducer towards the structuring of work management. It provided opportunities for municipalities to innovate in the relationship between work management and health education, in the constitution of different work processes, also enabling the incorporation of permanent education as a strategy to overcome the teaching-service dichotomy.

The work of the Cuban doctors was highlighted as differentiated, committed, gaining acceptance by the population due to the quality of the assistance provided, insofar as it is not based on the outpatient clinical profile, usually characteristic of the work of the Brazilian doctor.

The program was instrumental to generate autonomy for municipal administrations, insofar as it gave value to the manager with regard to the working relationship with the physicians, considering that it made possible for managers not to need to rely on scarce resources, few available professionals and the difficulty in being able to hire doctors willing to comply with the workload, recommended by the Ministry of Health for the Primary Care network. All this facts ended up inducing the organization of the work process in the PHC of the municipalities.

Regarding the relationship between the municipal management and other federated entities involved in the PMM, it was possible to identify that the constitution of the State Coordination Commission is an important space for dialogue and problem solving, as well as to allow the articulation and approximation between management and educational institutions. However, there is still a long way to go in terms of the articulation between teaching and service.

In the political scenario that the country has gone through, where it is possible to observe the complete dismantling of public policies advancing in large steps, there is a need to highlight the importance and significance that the Mais Médicos Program represented to overcome health inequities. This study adds up to the dozens of articles intended to study the PMM; and it comes to the conclusion that it represented the largest strategy for structuring work management, with regard to the supply of medical professionals in the country.

References

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