Implementation research: towards universal health coverage with more doctors in Brazil

Abstract

ObjectiveTo evaluate the implementation of a programme to provide primary care physicians for remote and deprived populations in Brazil.MethodsThe Mais Médicos (More Doctors) programme was launched in July 2013 with public calls to recruit physicians for priority areas. Other strategies were to increase primary care infrastructure investments and to provide more places at medical schools. We conducted a quasi-experimental, before-and-after evaluation of the implementation of the programme in 1708 municipalities with populations living in extreme poverty and in remote border areas. We compared physician density, primary care coverage and avoidable hospitalizations in municipalities enrolled (n = 1450) and not enrolled (n = 258) in the programme. Data extracted from health information systems and Ministry of Health publications were analysed.FindingsBy September 2015, 4917 physicians had been added to the 16 524 physicians already in place in municipalities with remote and deprived populations. The number of municipalities with ≥ 1.0 physician per 1000 inhabitants doubled from 163 in 2013 to 348 in 2015. Primary care coverage in enrolled municipalities (based on 3000 inhabitants per primary care team) increased from 77.9% in 2012 to 86.3% in 2015. Avoidable hospitalizations in enrolled municipalities decreased from 44.9% in 2012 to 41.2% in 2015, but remained unchanged in control municipalities. We also documented higher infrastructure investments in enrolled municipalities and an increase in the number of medical school places over the study period.ConclusionOther countries having shortages of physicians could benefit from the lessons of Brazil’s programme towards achieving universal right to health.

The end of Brazil’s More Doctors programme?

“…Before the More Doctors programme, the overall supply of doctors in the country (2 per 1000 population3) was only slightly lower than the supply in high income countries with universal health coverage: 2.83/1000 in the UK, 2.54 in Canada, and 3.50 in Australia 4. However, striking inequalities existed in Brazil, with over 42% of the population living in areas with fewer than 0.25 doctors per 1000 population 5…”

“…Priority was given to Brazilian doctors, but only 1096 enrolled 9. The gap was filled through an international cooperation agreement between Brazil and Cuba facilitated by PAHO, allowing up to 12 000 Cuban doctors to work in Brazil after basic training in primary care and supervision from an accredited university 310. In 2014, the $1.1bn (£900m; €1bn) costs of the programme were 93% financed by the federal budget and accounted for about $6000 a month for each doctor 11…”

“…Studies already report benefits, including fewer doctor shortages, more satisfied users, fewer avoidable hospital admissions, and service improvements such as better patient-doctor relationships, continuity of care, and multidisciplinary team coordination 391314…”

Cooperação internacional e escassez de médicos: análise da interação entre Brasil, Angola e Cuba

“…The program is also recognized by the PAHO as an innovative initiative, given the significant amount of financial resources invested in the recruitment of 11,400 doctors, the mobilization of doctors from a country like Cuba, which has a greater number of doctors per capita than Brazil, and the integration of these professionals into the SUS 40 . Recent assessments of the program show the following: 94.6% of the people attended under the program gave a good or very good satisfaction rating 41 ; the number of municipalities with a shortage of doctors decreased 42 ; there was an expansion in access to health care services in the most vulnerable regions 43 and a reduction in admissions for ambulatory care sensitive conditions in the Northeast Region 44 ; and a generally positive impact on admissions and access 45 . However, it is important to note that, given the recent creation of the program, academic evaluations and assessments by independent bodies are still underway.…”

Breaking down the barriers to universal health coverage

“…6 Brazil has used a package of incentives to recruit physicians to work in remote and deprived areas and to improve the primary health-care infrastructure, leading to better working conditions and better quality of care. 7 Political commitment can be decisive. A paper on the fate of underserved and marginalized populations during donor transition shows how limited political commitment can lead to the persecution of vulnerable groups, pointing to the need to engage key populations in planning, implementing, and monitoring the transition.…”