Brazil strives to replace its More Doctors programme for underserved regionsBMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m537 (Published 20 February 2020) Cite this as: BMJ 2020;368:m537
In September 2018 the residents of São José village, an indigenous settlement in Brazil’s state of Maranhão, lived in a spiral of medical uncertainty. Maranhão is marked by drought and lacks basic services such as water and sanitation. The only health centre near São José had just one doctor, José Domingues (name changed to protect identity). He had come from Cuba as part of a programme created by the Brazilian government. His three year contract was now finished, and he was ready to return to Cuba in a few days.
After that, however, anyone who got sick was out of luck. There were no plans to replace Domingues. In November 2018 the country’s recently elected president, Jair Bolsonaro, posted a message on his Twitter account1 saying that the government now required the More Doctors programme (Programa Mais Médicos; PMM) to subject its doctors to the same tests as other foreign doctors, pay them more, and allow the doctors to bring their families.
Thus ended—or radically changed—one of Brazil’s most comprehensive efforts to bring doctors, health teams, and outpatient clinics to underserved regions.
More Doctors was created in late 2013, during the first presidency of Dilma Rousseff. It was designed to tackle a problem that affects many nations, rich and poor: the misallocation of health professionals. While some places in Brazil have doctors to spare, others, especially rural areas, lack trained specialists to meet demand. Places such as São José village have no doctors at all.
In 2013, some 1200 cities in Brazil had a shortage of doctors. The north (the poorest region) had 0.98 doctors per 1000 inhabitants, while the south east (the richest) had 2.61 per 1000.2 “This inequality in distribution is a critical problem that impairs primary healthcare,” says Luiz Augusto Facchini, coordinator of the Brazilian Association of Collective Health.
The Brazilian Ministry of Health created More Doctors to renovate and construct small outpatient clinics and to revise medical school curriculums to focus on primary care. The third part of the plan received most of the attention: emergency provision of doctors to the neediest regions and cities. The proposal was a three year contract, which could then be renewed for a further three years. At first these opportunities were given to Brazilian doctors, but immediate interest was lacking. In the first month only 938 doctors applied for 15 460 job openings, representing only 6% of total demand.3
The Brazilian government followed up with a new plan, developed with the Pan American Health Organization: an agreement with the government of Cuba for it to start sending doctors to fill all kinds of vacancies. The agreement stated that Brazil would pay about 10 000 reals (£1794; €2126; $2321) a month for each professional, who would work 40 hours a week. This did not go straight to the doctors, however, but to the Cuban authorities, which delivered only a fraction of the money to the hired professionals.
The salary issue was one of the first problems. Brazilian doctors also protested the fact that Cuban professionals did not need to prove their education. To practise medicine in Brazil, all professionals trained abroad must be approved in a test called the revalida. In More Doctors, however, foreigners did not need to do this.
“The programme started out wrong in its conception and used a slave labour regime,” says Lincoln Ferreira, president of the Brazilian Medical Association . Some Cuban doctors were publicly booed by local healthcare professionals when they landed in Brazil.5 Protests by entities such as the medical association itself and the Federal Council of Medicine were so intense that they reached the Superior Federal Court, the highest body of Brazilian judges. In 2017, after a series of injunctions and judgments, the court concluded that the More Doctors programme complied with the Brazilian constitution and could continue.4
Despite the pushback, more than 26 000 basic health facilities were built or renovated throughout Brazil. At its peak the programme had 18 240 job positions: of these, 8332 were filled by Cubans, 4525 by Brazilians who had graduated locally, 2824 by Brazilians who had graduated abroad, and 451 by doctors of other nationalities.6 The number of municipalities with a shortage of doctors fell from 1200 in 2013 to 777 in 2015.2
A study by the Getúlio Vargas Foundation estimated that the increased presence of doctors in remote regions of the country had prevented a total of 521 000 hospital admissions in 2015, generating savings of 840m reals. This represents a third of the total amount invested in the entire programme during one year. Other studies showed greater satisfaction with public care, less medical absenteeism at work, and improvements in the doctor-patient relationship.6111213
“[More Doctors] was the boldest and most impactful experience of primary care we’ve had since the creation of our public health system in 1988,” says Arthur Chioro, professor at the Federal University of São Paulo and health minister from 2014 to 2015, during the Rousseff administration. “For a brief time we made sure that 63 million of the country’s poorest people had access to health, something that has always been available to other Brazilians.”
There were problems, however: reports of misuse of public funds for the construction of basic health facilities; cities that hired More Doctors medics and fired Brazilian locals to save money; and a chronic shortage of drugs and basic equipment for patient care.
In a recent review the Federal Council of Medicine reported an increase in maternal and child mortality rates during the same period and a drop in immunisation coverage throughout Brazil.7 The document concluded, “It is important to ascertain these events, as all are related to the provision of primary care, PMM’s [More Doctors’] main focus.”
However, no published study has linked More Doctors’ arrival with the drop in health indicators such as mortality and immunisation. No one knows for sure the reasons for these worsening, but many people suspect that the reduced healthcare investment as a result of Brazil’s financial crisis has had an impact.
The effects so far are anecdotal. “We are monitoring cities in the north and northeast regions of Brazil that were four or five months without any available doctors,” says Lígia Giovanella, professor at the National School of Public Health, Oswaldo Cruz Foundation, in Rio de Janeiro.
Vestiges of More Doctors remain. In February 2019 Brazil’s new government announced that 100% of the vacancies left by Cubans had been filled by Brazilians.8 Three months later, however, 1325 professionals had given up for several reasons, such as new job opportunities or lack of interest. This represented 19% of the total. It is not clear yet how all of these posts will be filled.9
To replace the More Doctors programme, in July 2019 Luiz Henrique Mandetta, the current health minister, announced the Doctors for Brazil programme (Programa Médicos pelo Brasil). The new proposal brings some changes, such as the creation of a public medical career. But it has no plan for improvements or more units in basic health or changes to the medical school curriculum.10
Erno Harzheim, secretary of primary healthcare at the Ministry of Health, says, “With the new programme, we want to have more objective indicators that allow us to evaluate the success of this strategy.” The project was discussed in the Brazilian House of Representatives and was approved by the end of 2019. The idea is to establish 18 000 job offers for doctors during 2020.14
In the face of so much debate, criticism, and plot twists, can anything be learnt from the Brazilian experience? Thomas Hone, professor at the School of Public Health of Imperial College London, UK, gives one possible answer. “[More Doctors] is a great opportunity to understand the impact that a doctor’s presence can have on a community,” he says. “The introduction of professionals in underserved areas brings results and increases universal access to health.”
As for José Domingues, he left for Cuba, where The BMJ has been unable to contact him, and there’s no mobile signal in São José village—but data from the Ministry of Health’s official report give signs of its current situation.15 The Basic Health Unit in São José village currently has 11 health professionals: five community health workers, three nursing technicians, two nurses, and one assistant in oral health.
No doctor is on the list. Whether the new Doctors for Brazil programme will change this remains to be seen.
I have read and understood BMJ policy on declaration of interests and declare the following interests: I am an employee of Editora Abril as a reporter of Saúde magazine, Brazil (https://saude.abril.com.br/). I occasionally receive travel support from pharmaceutical companies to attend scientific meetings and congresses.
Provenance and peer review: Commissioned; not externally peer reviewed.