The SUS needs more doctors and much more!



The street protests and consequential governmental responses have generated intense debate in Brazilian society regarding public policies, including those on health. For the Centro Brasileiro de Estudos de Saúde (CEBES - Brazilian Center for Health Studies), this is a time to celebrate the improved development and depth of Brazilian democracy. Our contribution in this debate demonstrates our stances on and proposals for the Brazilian health sector, compared to the Programa Mais Médicos (More Doctors Program), that the government has put forward as the strategy to meet public demands.

It's imperative to acknowledge that health care depends on health workers and their capacity to produce care. In an era when machinery, scans and technology are overvalued, it's necessary to reiterate that health is achieved with people. All health professions are fundamental for comprehensive care, that is, it is the health team that will be capable of treating and resolving all the problems presented by the public.

Sufficiently sized health care teams, if well distributed, will allow universal care of the population living in the whole country, fulfilling every Brazilian's constitutional right.

However, there is consensus among the managers of all spheres of the SUS that, out of all the health care occupations, physicians are the most difficult professionals to source within the public health service.

The population also recognises this problem; in a recent IPEA survey, public opinion indicated that the main problem of the SUS was a lack of doctors. Although disagreeing with that statement, which identifies a lack of physicians as the main problem in health care, CEBES cannot fail to acknowledge what various studies have shown: that there is a lack of doctors in Brazil, and this lack is especially prevalent in the SUS. Not in agreement with the arguments maintained by the medical authorities, who insist that there are enough doctors, CEBES points to both the shortage and ill distribution of physicians as a grave problem.

On the other hand, we underline that the main problem of the SUS is not a lack of doctors. In fact, this is just one of the symptoms of the chronic neglect in the implementation of the SUS, relegated by successive post-constitutional governments to the position of being a low quality system for the poor.

We must reiterate that the main problem of the SUS is the subordination of the health sector to market economics, which continue to expand and suffocate the constitutionally established social rights. This market logic treats health - and for that matter, disease - as merchandise, and the growth of this market, as has been witnessed in Brazil, distances health from the guiding principles of the SUS as an expression of health as a citizen's right.

It's necessary to examine the reasons why physicians refrain from joining the SUS and from occupying this vast empty territory for such professionals. In this regard, we refute the argument that it is only the bad structural and work conditions that explain the lack of doctors in the SUS. This could only be true if there were a group of unemployed doctors due to their refusal to accept inadequate conditions, which there isn't. On the contrary, practically all Brazilian doctors have one or more jobs, as studies have shown. Another, even more recent, IPEA survey shows that, on average, Brazilian doctors work 42 hours a week and earn approximately R$ 8,500.00 a month, placing them as the top earners among graduate professionals.

Brazil is experiencing a boom in the health market, in which one can already find the presence of major international capital and investment funds. This boom expresses the firm policy, which has been in place, of promoting and gearing the health sector toward the market, and thrives on the result of the social inclusion policy, based on expanding consumption, the tonic for economic policy of recent years.

This policy of increasing consumption, allied to omission, whether due to a lack of courage or bias in the correlation of forces, which has typified the last federal governments, that have failed to stand up to the interests of the economic forces in the health care industry (pharmaceutical industry, medical equipment, private health care plans and insurance, private service providers) and continue to promote chronic underfunding of the SUS, creating ideal conditions for the expansion of the health market. This is the main reason for the concentration of physicians in the private sector and their resulting scarcity in the public sector, a model that pillages the SUS and generates other severe distortions in Brazilian health care.

The crowds of Brazilians who took to the streets in cities around the country, demanding quality health and public services, to our eyes, are an expression of the possibility of triggering new social pacts, in and outside the health industry, creating effective conditions for a change in this correlation of forces to prioritise public interest before economic interests.

In this context of positioning the right to health at the centre of the political project for social and economic development of the country, CEBES calls attention to the fact that the measures that form the More Doctors Program are necessary and praiseworthy, however, insufficient for the sector, which is in urgent need of other short-, mid- and long-term structuring measures. With these references to the understanding of the crisis in the sector, we express our concern and present proposals relative to the Pact for Health, formulated by the Federal Government:

• In light of the unjust lack of medical care that afflicts the population and the difficulty that managers experience in hiring medical professionals, the initiative to attract foreign doctors to the country is extremely welcome. However, such a measure should be of an emergency and focused character in answer to the public outcry expressed on the streets, which openly condemned the fact that substantial sections of the population are not ensured their constitutional right to health care. Structuring measures must be adopted simultaneously to address the issue;

• Even without touching on the grave problem of underfunding of the health sector, the announcement of investments in health care facilities, especially in the Primary Care Network, constitutes an important and necessary measure, which respects the health professionals and, above all, the users of the SUS. The adequate and long-term measure is to guarantee financing for permanent investments in the system;

• Further curricular changes in medical training are required, beyond simply extending the course duration. From that perspective, the Ministry of Health, as the national manager of the Unified Health System, should make use of its constitutional duty to "organise the training of human resources in the area of health", established in item III of article 200 of the charter;

• Universities need to have as their primary mission to train health professionals with the required profile for the needs of the Brazilian public, in other words, to work in the SUS. It is, therefore, essential that teaching is entirely integrated into the Health Care Network, and that the barriers that separate teaching hospitals from the SUS are broken down;

• Equally necessary is an increase in places on undergraduate medicine course essentially at public universities, and in places that are in most need of physicians. It's necessary to broaden access to medical schools, particularly outside the capitals, which should be achieved by expanding the network of federal universities;

• Just as important as training medics with the ethical and human profile to work in the SUS is to train specialists required to ensure comprehensive care. Medical Residency programs must also be made universal and compulsory, guaranteeing places for all student doctors according to the needs of the Unified Health System;

• We should also support the federal government's strategic hiring of Brazilian doctors to work in poorly resourced towns and areas, where the lack of such professionals is felt most acutely by the population. But changes are required in the Fiscal Responsibility Act, which limits municipal and state capability to hire health professionals, who should preferentially be institutionally bound to the municipalities;

• The National Plan of Jobs, Careers and Salaries for SUS employees should be created and implemented immediately, as indicated in the last National Health Conference. CEBES defends the immediate creation of the national career in the mould defined by the SUS Permanent Negotiating Table.

It is essential that the federal government knows how to take advantage of this moment in which Brazilian society demands public health services with guaranteed access and quality, and corrects the mistake represented by the regulation of Constitutional Amendment 29, without the commitment of 10% of the Gross Federal Revenue to health.

With the withdrawal of incentives and fiscal waivers for private health plans and insurance, and with increased funds from pre-salt oil exploration royalties and wealth tax, it would be perfectly possible to guarantee this minimum level of investment in the health of Brazilians, without it causing any fiscal imbalance.

We are convinced that, with adequate investment and the courage needed to stand up to the economic interests that pervade the health sector, it would be possible and necessary to consolidate the citizens' right to health and the Unified Health System, as demanded by the Brazilian population. The SUS Needs More Doctors and Much More...


The National Board

Centro Brasileiro de Estudos de Saúde RJ - Brazil
E-mail: revista@saudeemdebate.org.br