Addressing inequalities in medical workforce distribution: evidence from a quasi-experimental study in Brazil

Abstract

BackgroundBrazil faces huge health inequality challenges since not all municipalities have access to primary care physicians. The More Doctors Programme (MDP), which started in 2013, was born out of this recognition, providing more than 18 000 doctors in the first few years. However, the programme faced a restructuring at the end of 2018.MethodsWe construct a panel municipality-level data between 2008 and 2017 for 5570 municipalities in Brazil. We employ a difference-in-differences empirical approach, combined with propensity score matching, to study the impacts of the programme on hospitalisations for ambulatory care sensitive conditions and its costs. We explore heterogeneous impacts by age of the patients, type of admissions, and municipalities that were given priority.FindingsThe MDP reduced ambulatory admissions by 2.9 per cent (p value <0.10) and the costs by 3.7 per cent (p value <0.01) over the mean. The reduction was driven by infectious gastroenteritis, bacterial pneumonias, asthma, kidney and urinary infections, and pelvic inflammatory disease. The results held on the subsample of municipalities targeted by the programme. By comparing the benefits of the programme from the reduction in the costs of ambulatory admissions to the total financial costs of the MDP, the impacts allowed the government to save at least BRL 27.88 (US$ 6.9 million) between 2014 and 2017.ConclusionAddressing inequalities in the distribution of the medical workforce remains a global challenge. Our results inform the discussion on the current strategy adopted in Brazil to increase access to primary healthcare in underserved areas.

Impact of the Programa Mais médicos (more doctors Programme) on primary care doctor supply and amenable mortality: quasi-experimental study of 5565 Brazilian municipalities

“…Fifthly, the PMM may have prompted better recording and doctor allocation by local health system managers, and the substitution effect could partly have come from absent doctors being removed from the system. Evidence is growing that large-scale health system interventions to address HRH supply shortages can deliver health gains [1,20]. However, this study demonstrates the importance of developing and adhering to comprehensive needs-based criteria for HRH allocation.…”

“…Studies show that following the PMM there are now fewer municipalities with primary care doctor shortages [ 16 , 17 ], access to doctors has increased, users are more satisfied, and services have improved including patient-doctor relations, continuity, and coordination [ 18 , 19 ]. There is also evidence of reductions in hospitalisations, but no effect on infant mortality [ 20 , 21 ]. However, little is known about PMM’s impact on existing primary care services or adult mortality.…”

Impact of Brazil's More Doctors Program on hospitalizations for primary care sensitive cardiovascular conditions

“…cardiovascular conditions). Maffioli and colleagues recently corroborated the results generated by Fontes et al., 2018 , though they did not provide evidence on cardiovascular conditions ( Maffioli et al, 2019 ). More recently, Mattos and Mazetto (2019) using a sample of 2940 municipalities with populations of less than 500,000 inhabitants and showed that the MDP led to reductions in general hospitalizations between 2010 and 2015.…”

Brazil Health Care System preparation against COVID-19

“…To evaluate the geographical accessibility to emergency care service care was used the two-step floating catchment area (2SFCA) technique. With this approach, it was possible to assess the accessibility to emergency care services by the interaction of two geographic characteristics: (a) the volume of available hospital beds weighted by population within 2 hours of travel distance, and (b) the proximity of hospitals within a 2 hours displacement from each municipality (11). The 2SFCA method generated two accessibility indexes for each municipality in Brazil, one regarding the network available in February 2020, and a secondary one highlighting where the COVID-19 new exclusive beds increased the access to emergency services.…”

“…Due to the COVID-19 consequences, the scenario faced by low and medium income countries is even more staggering (7). The historic challenges regarding an insufficient number of health professionals, iniquities in distribution of human resources (11), low accessibility to emergency care services (ECS) (12) and economic issues creates additional pressures to be addressed, aiming is to achieve an adequate COVID-19 response.…”