The article by Heider Pinto and colleagues11 Pinto HA, Andreazza R, Ribeiro RJ, Loula MR, Reis AAC. O Programa Mais Médicos e a mudança do papel do Estado na regulação e ordenação da formação médica. Interface (Botucatu). 2019; 23(Supl. 1): e170960 . brings up elements that are worth being discussed under the perspective of the public policy cycle. Therefore, even though the authors express its statute engaged in the policy they intend to analyze, its reflection is relevant to the academic debate itself and to inform future governing actions.
The article shows to which extent the policy decision-making process is based on circumstances. In order to speak of processes, we need to understand different public policy cycles: emergency and issue agenda; and policy formulation, implementation and assessment22 Rodrigues M. Exercícios de análise de políticas públicas. Lisboa: Imprensa Nacional-Casa da Moeda e ISCTE-IUL; 2014.. In order to speak of circumstances, we need to understand the feasibility of fulfilling policy cycles. Basically, it is about opening the governing action’s “black box,” understanding that decisions made throughout policy cycles result from the momentary structure and organization of groups of interest33 Bourgeault IL. Conceptualizing the social and political context of the health workforce: health professions, the state, and its gender dimensions. Front Sociol. 2017; 2:16. doi: 10.3389/fsoc.2017.00016.
https://doi.org/10.3389/fsoc.2017.00016... . These groups include wider political communities (political parties and multiple social organization movements with political purposes), as well as professions, market, international regulation instances and, obviously, universities.
The argument is that the structural aspect of the More Doctors Program (PMM) adopted in Brazil was aimed at reconfiguring the State’s role in the regulation of the health workforce from the supply and education points of view, and consequently of care practices.
Regarding the policy’s emergency, the article indicates two issues PMM aimed at addressing. One of them was the disequilibrium of doctors in the territory, both in general terms and in certain specialties. The other was the State’s need to regulate medical education under the perspective of supply and education. The authors’ argument is that the first issue is a result of the second. It is simple to understand: governments are not able to ensure commitment to comprehensive and universal care if not through mechanisms that control and predict different means necessary in this service provision. These means include technology, infrastructure, knowledge and professionals. Lack of political action in some of these means expose health systems to the market, partial interests or both, in different levels. The difficulty to nationally regulate the global health technology and innovation market (e.g., drugs) is well-known. Making efforts towards what can be efficiently regulated within a country’s borders is an added reason for this difficulty. Knowledge and professionals are examples of that.
Nevertheless, disequilibria in the supply of a health workforce is found in most countries, even in those that strengthened the state regulation on education seats. This does not mean that the state regulation is irrelevant for the availability of working professionals. Once again, data found by Pinto and colleagues shows the opposite: the market’s self-regulation not only is not adequate to ensuring care provision to all in all phases of life44 United Nations. Transforming our world: the 2030 agenda for sustainable development. New York: United Nations; 2015. but also is permeable to corporate and partial interests.
What is at stake is an aspect that goes beyond the scope of analysis of Pinto and colleagues, but that should guide future debates on PMM: retention of a health workforce. Answers to the following questions are necessary: to which extent doctors (health workforce in general) have territorial mobility dynamics to work in the Brazilian National Health System (SUS)? Which are the reasons for these dynamics? To which extent are these dynamics desirable or undesirable in organizing and planning care, and politically adjustable?
The distribution of working professionals is a result of problems related to the retention of a health workforce (which can also be explained among countries where education regulation was strengthened), which can keep presenting disequilibria.
Regarding the policy agenda, the elements mentioned in the article enable to frame PMM’s creation, in 2013, and its relative suspension starting from 2016 under several theoretical perspectives, which should be further developed by future analyses. One of them is the streams metaphor55 Kingdom J. Agendas, alternatives, and public policies. New York: Longman; 2003.. According to it, windows of opportunity to the emergence of a policy result from the coexistence of three streams: problems (perception of the existence of a problem that needs to be solved), policy proposals (having concrete policy solutions and strategies) and political events (favorable governance conditions). Another perspective is the punctuated equilibrium66 Baumgartner F, Breunig C, Green-Pedersen C, Jones BD, Mortensen PB, Nuytemans M, et al. Punctuated equilibrium in comparative perspective. Am J Polit Sci. 2009; 53(3):602-19.. According to it, the emergence and end of a public policy cycle result from the dispute of political monopolies. Consequently, the political understanding about disequilibria in the distribution of medical education seats being a problem or not explains, right from the start, the propensity for government action or omission. This perspective helps show to which extent the political game is populated by several groups of interest, some of them opposed, from the point of view of values and understanding the role and function of other agents of the political system. The equilibrium is punctuated because, in different moments, the relationship of power among them is changed. The third perspective is related to cycles of public and media attention to problems77 Hogwood B, Peters BG. Policy dynamics. New York: St. Martin's Press; 1983.. Being aware of the public opinion and media influence on policy agendas, the relative abandonment of PMM’s policy implementation after 2016 shows poor public adherence or media unfamiliarity. Both possibilities show to which extent mass dissemination should follow policy agenda so that policy formulation is more appropriate to different sectors of the society.
Regarding policy formulation, the article indicates elements framed by different perspectives that should be further comprehended by future analyses. One of these perspectives is path dependence88 Pierson P. Increasing returns, path dependence and the study of politics. Am Polit Sci Rev. 2000; 94(2):251-67., considering previous political elements on which PMM was based. However, innovation brought by reinforcing the state regulation on education and distribution of seats shows mixed approaches: focused on agents99 Dye T. Understanding public policy. Boston: Longman; 2012. and focused on policy transfer1010 Dolowitz D, Marsh D. Learning from abroad: the role of policy transfer in contemporary policy-making. Governance. 2000; 13(1):5-24.. The first ones highlight the active role played by key agents in the design of public policies; therefore, to which extent and which individual agents created PMM in 2013. Likewise, it is necessary to realize to which extent, how and which individual agents changed PMM after 2016. The second approaches highlight the international influence on the design of national policies, i.e., to which extent and how PMM resulted from international organizations’ guidance (such as the World Health Organization, Organization for Economic Co-operation and Development, etc.) and how this influence was adapted to the national context.
Regarding the policy implementation (and why the apparently rupture in PMM’s cycle in 2016 only enables to partially assess its effects), the article provides detailed elements and shows to which extent PMM’s origin was based on the systemic understanding required by government actions in health. The information also enables to ask new questions for future analyses, including to further understand the post-2016 change. The international evidence legitimizes the structuring axis PMM tried to implement in 2013. The point is that lessons can be learned on the way the implementation was conducted in order to enable, in the future, to continue with PMM, even if faced by unfavorable government cycles. The implementation of public policies is more effective the greater their adoption by wide sectors of the society is. This ensures their stability in different government cycles. Therefore, there is an interest to know how PMM was being perceived by the diversity of agents and what motivated its change in 2016. To which extent its 2016 purpose was not to “nip the policy in the bud” before it was effectively adopted by the agents? On the other hand, if there was enough time for its adoption, what explains the policy’s poor adoption? Was there resistance to the government cycle change in 2016? Which are the necessary conditions for PMM to try to achieve its objective? Clear answers to these questions will constitute a valuable resource to further inform and, if possible, change the government action.
- 1Pinto HA, Andreazza R, Ribeiro RJ, Loula MR, Reis AAC. O Programa Mais Médicos e a mudança do papel do Estado na regulação e ordenação da formação médica. Interface (Botucatu). 2019; 23(Supl. 1): e170960 .
- 2Rodrigues M. Exercícios de análise de políticas públicas. Lisboa: Imprensa Nacional-Casa da Moeda e ISCTE-IUL; 2014.
- 3Bourgeault IL. Conceptualizing the social and political context of the health workforce: health professions, the state, and its gender dimensions. Front Sociol. 2017; 2:16. doi: 10.3389/fsoc.2017.00016.
- 4United Nations. Transforming our world: the 2030 agenda for sustainable development. New York: United Nations; 2015.
- 5Kingdom J. Agendas, alternatives, and public policies. New York: Longman; 2003.
- 6Baumgartner F, Breunig C, Green-Pedersen C, Jones BD, Mortensen PB, Nuytemans M, et al. Punctuated equilibrium in comparative perspective. Am J Polit Sci. 2009; 53(3):602-19.
- 7Hogwood B, Peters BG. Policy dynamics. New York: St. Martin's Press; 1983.
- 8Pierson P. Increasing returns, path dependence and the study of politics. Am Polit Sci Rev. 2000; 94(2):251-67.
- 9Dye T. Understanding public policy. Boston: Longman; 2012.
- 10Dolowitz D, Marsh D. Learning from abroad: the role of policy transfer in contemporary policy-making. Governance. 2000; 13(1):5-24.
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05 Nov 2018