ResumoObjetivando traçar a evolução histórica da distribuição de médicos no Brasil segundo sexo, foi realizado estudo epidemiológico do tipo ecológico, por meio do cruzamento de bancos de dados secundários (linkage). Para a caracterização geral dos médicos foram consideradas as bases de dados dos 27 conselhos regionais de medicina, complementadas pelas bases de dados da Comissão Nacional de Residência Médica e da Associação Médica Brasileira. Os resultados mostram que, desde 2009, entre os novos médicos registrados há mais mulheres que homens. Na população de médicos em atividade os homens ainda predominam (60,1%), mas no grupo com 29 anos ou menos as mulheres já são maioria. A tendência consistente de maior participação das mulheres na profissão médica no Brasil, observada ao longo das últimas décadas e acentuada nos últimos anos, indica a necessidade de reavaliar e readequar as propostas para implementação de políticas públicas na área. Palavras-chave: Feminização. Medicina. Distribuição de médicos. Brasil. Resumen La feminización de la Medicina en BrasilCon el fin de trazar la evolución histórica de la distribución de los médicos en Brasil por sexo, se llevó a cabo un estudio epidemiológico del tipo ecológico, a través de la intersección de las bases de datos secundarias (linkage). Para la caracterización general de los médicos, se han considerado las bases de datos de los 27 Consejos Regionales de Medicina, complementados con las bases de datos de la Comisión Nacional de Residencia Médica y de la Asociación Médica Brasileña. Los resultados muestran que entre los nuevos médicos colegiados hay más mujeres que hombres desde 2009. En la población de los médicos en actividad todavía predominan los hombres (60,1%), pero en el grupo con 29 años o menos, las mujeres son la mayoría. La tendencia constante de aumento de la participación de las mujeres en la profesión médica en Brasil, observada durante las últimas décadas y notablemente en los últimos años, indica la necesidad de reevaluar y reajustar las propuestas para la implementación de políticas públicas en el área. Palabras-clave: Feminización. Medicina. Distribución de médicos. Brasil. Abstract The feminization of Medicine in BrazilAiming to settle the historical evolution of physicians' distribution in Brazil by gender, an ecological study was conducted by secondary database cross-checking (linkage). For a general characterization of the physicians were considered the 27 Regional Medicine Council, complemented by the National Medical Residency and the Brazilian Medical Association databases. The results show that since 2009, among new registered doctors there are more women than men. Although men still prevail (60.1%) in the active physicians population, in the group aged less than 29 years old, women have become majority. The consistent trend of increased participation of women in the medical profession in Brazil, observed over the past decades and intensified over the past few years, indicates the need to reassess and readjust the proposals for implementati...

BackgroundBrazil boasts a health scheme that aspires to provide universal coverage, but its surgical system has rarely been analysed. In an effort to strengthen surgical systems worldwide, the Lancet Commission on Global Surgery proposed a collection of 6 standardised indicators: 2-hour access to surgery, surgical workforce density, surgical volume, perioperative mortality rate (POMR) and protection against impoverishing and catastrophic expenditure. This study aims to characterise the Brazilian surgical health system with these newly devised indicators while gaining understanding on the complexity of the indicators themselves.MethodsUsing Brazil's national healthcare database, commonly reported healthcare variables were used to calculate or simulate the 6 surgical indicators. Access to surgery was calculated using hospital locations, surgical workforce density was calculated using locations of surgeons, anaesthesiologists and obstetricians (SAO), and surgical volume and POMR were identified with surgical procedure codes. The rates of protection against impoverishing and catastrophic expenditure were modelled using cost of surgical inpatient hospitalisations and a γ distribution of incomes based on Gini and gross domestic product/capita.FindingsIn 2014, SAO density was 34.7/100 000 population, surgical volume was 4433 procedures/100 000 people and POMR was 1.71%. 79.4% of surgical patients were protected against impoverishing expenditure and 84.6% were protected against catastrophic expenditure due to surgery each year. 2-hour access to surgery was not able to be calculated from national health data, but a proxy measure suggested that 97.2% of the population has 2-hour access to a hospital that may be able to provide surgery. Geographic disparities were seen in all indicators.InterpretationBrazil's public surgical system meets several key benchmarks. Geographic disparities, however, are substantial and raise concerns of equity. Policies should focus on stimulating appropriate geographic allocation of the surgical workforce and better distribution of surgical volume. In some cases, where benchmarks for each indicator are met, supplemental analysis can further inform our understanding of health systems. This measured and systematic evaluation should be encouraged for all nations seeking to better understand their surgical systems.

BackgroundLike other countries, Brazil is struggling with issues related to public policies designed to influence the distribution, establishment, supply and education of doctors.While the number of undergraduate medical schools and places available on medical schools has risen, the increase in the number of doctors in Brazil in recent decades has not benefitted the population homogeneously.The government has expanded the medical schools at the country’s federal universities, while providing incentives for the creation of new undergraduate courses at private establishments. This article examines the trends and challenges of the privatization of medical education in Brazil.MethodsThis is a descriptive, cross-sectional study based on secondary data from official government databases on medical schools and courses and institutions offering such courses in Brazil. It takes into account the year when the medical schools received authorization to initiatte the activities, where they are situated, whether they are run by a public or private entity, how many places they offer, how many students they have enrolled, and their performance according to Ministry ofEducation evaluations.ResultsBrazil had 241 medical schools in 2014, offering a total of 20,340 places. The private higher education institutions are responsible for most of the enrolment of medical students nationally (54 %), especially in the southeast. However, enrolment in public institutions predominate more in the capitals than in other cities. Overal, the public medical schools performed better than the private schools in the last two National Exam of Students’ (ENADE) .ConclusionThe privatization of the teaching of medicine at undergraduate level in Brazil represents a great challenge: how to expand the number of places while assuring quality and democratic access to this form of education. Upon seeking to understand the configuration and trends in medical education in Brazil, it is hoped that this analysis may contribute to a broader research agenda in the future.

BackgroundThe intertwined relation between public and private care in Brazil is reshaping the medical profession, possibly affecting the distribution and profile of the country’s medical workforce. Physicians’ simultaneous engagement in public and private services is a common and unregulated practice in Brazil, but the influence played by contextual factors and personal characteristics over dual practice engagement are still poorly understood. This study aimed at exploring the sociodemographic profile of Brazilian physicians to shed light on the links between their personal characteristics and their distribution across public and private services.MethodsA nation-wide cross-sectional study using primary data was conducted in 2014. A representative sample size of 2400 physicians was calculated based  on the National Council of Medicine database registries; telephone interviews were conducted to explore physicians’ sociodemographic characteristics and their engagement with public and private services.ResultsFrom the 2400 physicians included, 51.45% were currently working in both the public and private services, while 26.95% and 21.58% were working exclusively in the private and public sectors, respectively. Public sector physicians were found to be younger (PR 0.84 [0.68–0.89]; PR 0.47 [0.38–0.56]), less experienced (PR 0.78 [0.73–0.94]; PR 0.44 [0.36–0.53]) and predominantly female (PR 0.79 [0.71–0.88]; PR 0.68 [0.6–0.78]) when compared to dual and private practitioners; their income was substantially lower than those working exclusively for the private (PR 0.58 [0.48–0.69]) and mixed sectors (PR 0.31 [0.25–0.37]). Conversely, physicians from the private sector were found to be typically senior (PR 1.96 [1.58–2.43]), specialized (PR 1.29 [1.17–1.42]) and male (PR 1.35 [1.21–1.51]), often working less than 20 h per week (PR 2.04 [1.4–2.96]). Dual practitioners were mostly middle-aged (PR 1.3 [1.16–1.45]), male specialists with 10 to 30 years of medical practice (PR 1.23 [1.11–1.37]).ConclusionThe study shows that more than half of Brazilian physicians currently engage with dual practice, while only one fifth dedicate exclusively to public services, highlighting also substantial differences in socio-demographic and work-related characteristics between public, private and dual-practitioners. These results are consistent with the international literature suggesting that physicians’ sociodemographic characteristics can help predict dual practice forms and prevalence in a country.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3076-z) contains supplementary material, which is available to authorized users.

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IntroductionAlthough economic crises are common in low/middle-income countries (LMICs), the evidence of their impact on health systems is still scant. We conducted a comparative case study of Maranhão and São Paulo, two unevenly developed states in Brazil, to explore the health financing and system performance changes brought in by its 2014–2015 economic recession.MethodsDrawing from economic and health system research literature, we designed a conceptual framework exploring the links between macroeconomic factors, labour markets, demand and supply of health services and system performance. We used data from the National Health Accounts and National Household Sample Survey to examine changes in Brazil’s health spending over the 2010–2018 period. Data from the National Agency of Supplementary Health database and the public health budget information system were employed to compare and contrast health financing and system performance of São Paulo and Maranhão.ResultsOur analysis shows that Brazil’s macroeconomic conditions deteriorated across the board after 2015–2016, with São Paulo’s economy experiencing a wider setback than Maranhão’s. We showed how public health expenditures flattened, while private health insurance expenditures increased due to the recession. Public financing patterns differed across the two states, as health funding in Maranhão continued to grow after the crisis years, as it was propped up by transfers to local governments. While public sector staff and beds per capita in Maranhão were not affected by the crisis, a decrease in public physicians was observed in São Paulo.ConclusionOur case study suggests that in a complex heterogeneous system, economic recessions reverberate unequally across its parts, as the effects are mediated by private spending, structure of the market and adjustments in public financing. Policies aimed at mitigating the effects of recessions in LMICs will need to take such differences into account.

Programa Mais Médicos: em busca de respostas satisfatórias More Doctors Program: in search of satisfying answers Programa Más Médicos: en busca de respuestas satisfactorias O artigo em debate, ao apresentar os sistemas de saúde australiano e norteamericano, em contraste com o Brasil, traz um panorama sobre o difícil desafio, compartilhado por diversos países, de enfrentar a má distribuição ou a falta localizada de médicos.No sentido de ampliar o debate e evidenciar sua complexidade, tomam-se por base duas extensas revisões publicadas 1,2 que recensearam medidas destinadas a garantir a presença de médicos em áreas desassistidas, em interiores e subúrbios.Esses estudos sublinham que as respostas não são únicas e nem mesmo duráveis ou satisfatórias.Alguns fatores-chave, determinantes da escolha, pelo médico, do lugar de seu exercício profissional, têm sistematicamente influenciado a recorrência do problema.Por exemplo, sabe-se que a ausência de atratividade de regiões com piores indicadores sociais e as condições inadequadas de trabalho, com cargas horárias excessivas e má remuneração, dificultam a fixação de médicos. A renda elevada pode não ser uma compensação quando médicos são submetidos ao isolamento profissional e à baixa qualidade de vida deles próprios e de seus familiares.Não há que contar com o assistencialismo de base filantrópica individual e pessoal de médicos decididos a cobrirem populações carentes. O altruísmo que caracterizou o início da profissão médica moderna, há muito foi substituído pela ideologia profissional de valorização das ultraespecialidades, dos altos rendimentos pessoais e da transformação dos próprios consultórios em microempresa inserida num competitivo mercado de negócios 3 . Nesse sentido, um dos apelos possíveis está locado nas políticas públicas e gestões macroeconômicas, que produzem desenvolvimento regional e ajudam a corrigir alguns aspectos geradores da má distribuição de efetivos médicos.Além regiões menos atrativas; o segundo, dirigido aos médicos já em atividade, inclui incentivos financeiros e regulatórios para deslocar os profissionais que vivem concentrados em determinadas regiões e atividades; o terceiro prevê alternativas que envolvam outros profissionais de saúde combinadas com tecnologias de telemedicina e assistência à distância. As intervenções diversas adotadas por países 2 tentam agir sobre diferentes momentos do percurso profissional: na formação inicial, no recrutamento ou instalação, na fixação ou manutenção do médico no local do trabalho.Há limites claros de, pelo menos, três medidas mobilizadas: 1) o aumento do número global de médicos é ineficaz, pois gera saturação da oferta e concorrência exacerbada em áreas onde já existe alta densidade de médicos; 2) os incrementos financeiros são insuficientes, pois tal política tem custo elevado, estimula a permanência provisória e não fixa médicos em médio e longo prazo. Da mesma forma, assistiram impacto relativo, não sustentável, países que promoveram ajuda monetária, bolsas, bônus, condições compensatórias e pre...

ObjectiveIn many countries an increase in the number of women in medicine is accompanied by gender inequality in various aspects of professional practice. Women in medical workforce usually earn less than their male counterparts. The aim of this study was to describe the gender wage difference and analyse the associated factors in relation to Brazil’s physicians.Participants2400 physicians.SettingNationwide, cross-sectional study conducted in 2014.MethodsData were collected via a telephone enquiry. Sociodemographic and work characteristics were considered factors, and monthly wages (only the monthly earnings based on a medical profession) were considered as the primary outcome. A hierarchical multiple regression model was used to study the factors related to wage differences between male and female physicians. The adjustment of different models was verified by indicators of residual deviance and the Akaike information criterion. Analysis of variance was used to verify the equality hypothesis subsequently among the different models.ResultsThe probability of men receiving the highest monthly wage range is higher than women for all factors. Almost 80% of women are concentrated in the three lowest wage categories, while 51% of men are in the three highest categories. Among physicians working between 20 and 40 hours a week, only 2.7% of women reported receiving >US$10 762 per month, compared with 13% of men. After adjustment for work characteristics in the hierarchical multiple regression model, the gender variable estimations (ß) remained, with no significant modifications. The final effect of this full model suggests that the probability of men receiving the highest salary level (≥US$10 762) is 17.1%, and for women it is 4.1%. Results indicate that a significant gender wage difference exists in Brazil.ConclusionThe inequality between sexes persisted even after adjusting for working factors such as weekly workload, number of weekly on-call shifts, physician office work, length of practice and specialisation.