The More Doctors Program in remote areas : the experience of the Special Supervision Group in Pará , Brazil

(a) Departamento de Medicina Preventiva e Social, Faculdade de Medicina, Universidade Federal de Minas Gerais. Avenida Alfredo Balena, 190, Sala 801, Santa Efigênia. Belo Horizonte, MG, Brasil. 30130-100. (b) Centro de Educação a Distância, Universidade de Brasília. Brasília, DF, Brasil. The More Doctors Program in remote areas: the experience of the Special Supervision Group in Pará, Brazil (abstract: p. 12) El Programa Más Médicos en áreas remotas: la experiencia del Grupo Especial de Supervisión en el estado de Pará, Brasil (resumen: p. 12)


Introduction
The employment of foreign doctors in contexts of shortage of these professionals in different health systems, particularly in primary care, is a constant in diverse countries.Commonly known as International Medical Graduates (IMG), these professionals significantly contribute to the functioning of primary care in countries like the United States [1][2][3][4][5] and Canada [6][7][8][9] .Great Britain had, in 2013, 16% of IMGs among its general practitioners (GPs) aged between thirty and fifty years old, and 19% in the age group older than fifty years 10 .
The reasons for this shortage are usually attributed to the doctors' unwillingness to pursue careers in primary care in these countries, or to a high turnover of the professionals who act in this context as they search for better working conditions 11,12 .Aiming to tackle this problem, different countries have developed programs or initiatives to supply doctors -foreign or not -to regions with a history of shortage of these professionals.Some examples are the Canadian return-for-service programs 13 , the American programs that grant special visas to foreign doctors (J-1 Visa Waiver) 14 , and incentives to attract foreign doctors to primary care in the United Kingdom 15 .It is also possible to find, in the international literature, examples of policies for the supply of doctors in Bangladesh 16 , Norway 17 and Australia 18 , among others.
As examples of incentives to attract and retain health professionals in developing countries, we cite recruitment and training initiatives in rural areas (Thailand); practical educational routes targeted at problem-solving and focusing on students and the community (Ethiopia, Ghana and Kenya); use of financial incentives, facilities for training and compulsory service (Indonesia, Thailand, South Africa, Zambia, Mexico and Ecuador); focus on the improvement in living and housing conditions in remote areas (Thailand and Zambia) 19 .
In Brazil, the shortage of medical professionals in certain geographical regions has been studied at least since the 1970s, when the public health officer Carlos Gentile de Mello published the first studies on the theme 11  In the PMM proposal, there is a component or action axis called emergency supply of doctors, which is composed of the Project More Doctors for Brazil (PMMB).The other axes refer to investments in the infrastructure of Primary Care Units (UBS), increases in the number of seats in Medicine and Medical Residency courses -the latter targeted at Family and Community Medicine -, and to the National Curricular Guidelines (DCN), which were reviewed and republished in June 2014, with a redefinition of structuring axes to the Medicine courses.
PMM is managed mainly by the Ministry of Health, but there are partnerships with different institutions.The Ministry of Education (MEC), for example, is co-responsible for the management of PMMB.MEC provides the initial qualifications and is responsible for the process of continuous academic supervision, that is, it is in charge of the majority of the elements that form the emergency supply axis.
The present article is an experience report that approaches the formation and action of the Special Supervision Group of the More Doctors Program in the state of Pará (GES/Pará), Northern Brazil, instituted by MEC by means of Directive no.28 of July 14, 2015.Because it is a report, the facts and data presented here are based on official documents and on the authors' experience and analyses of the working processes, as the authors have been linked to GES since its early months.

Professional supervision strategies in medical supply programs
Programs for the supply of medical professionals are planned with specific strategies of supervision and professional qualification.As they have professionals who graduated outside the context in which they will work, these programs need to provide benefits to stimulate those professionals' retention.These strategies also have legal importance when, in some settings, professional practice without the required license is conditioned to periodic supervision and qualification actions.
To guarantee adequate qualification for these professionals, as well as the necessary adaptation to their contexts, countries that usually employ foreign doctors use different strategies.In Norway, for example, specific education programs in Family Medicine and Public Health, based on in-service training and tutorial groups, are designed to take place in any area of the country 17 .In the United Kingdom, to be able to have the full professional registration, doctors graduated in other countries and also those who graduated in the UK must undergo a process known as approved practice setting (APS), composed of a scheme of direct professional supervision and assessments 22 .Countries like Canada, Australia and New Zealand also maintain the requirement of supervised professional practice for foreign doctors working in primary care services [23][24][25] .
In Brazil, doctors' participation in teaching-service integration activities is a condition for their permanence in the More Doctors Program.For this reason, professional qualification actions are composed of two educational cycles: the first is subdivided into the educational axes "Specialization and Academic Supervision", and the second is subdivided into "Improvement and Extension".There is also the selective education known as "Embracement and Assessment Module" (MAAv), attended by doctors who want to join PMM and graduated abroad (both Brazilians and foreigners).While MAAv is offered in the face-to-face format, the specialization courses, carried out in the first two years of the professional's permanence in Brazil, and the improvement and extension axis, carried out after the specialization courses, are offered in the distance modality.
Academic supervision, which must occur throughout the professional's stay in Brazil, is usually offered on a monthly basis, in the face-to-face modality.However, the country's vastness and the low population density of many places create difficulties inherent in these conditions, as the professional supervisors' monthly presence in certain areas is not always possible.Therefore, the Special Supervision Group of the More Doctors Program was created in 2014 to act in the North region of Brazil, characterized by the conditions mentioned above.

The Special Supervision Group
The Special Supervision Group (GES) emerged in a context in which the supervisory institutions of the North region were having difficulties in maintaining the regularity of the academic supervisions conducted by professionals linked to them.It is a management strategy to face the challenge of delivering academic supervision in that region of the country, in collaboration with supervisory institutions, local councils of municipal health secretaries (COSEMS) and the Armed Forces, based on agreements made by MEC's management nucleus with the Presidency of the Republic and the Ministry of Defense.
Directive 28/2015 26 supports GES, and clarifies and regulates the Group's objectives, namely: Art. 2 GES' objectives are: I -To deliver academic supervision, in a permanent or temporary way, to PMMB professionals working in areas where the transportation of supervisors from the supervisory institutions is difficult; II -To reestablish the participant doctor's contact with the pedagogical actions of PMMB; III -To establish a partnership with the local supervisory institution concerning the provision of information on the situation of the monitored PMMB doctors; IV -To perform a situational diagnosis of the academic supervision, providing feedback for the local manager or their legal representative; V -To strengthen the assessment processes of the academic supervision among the participant doctors; VI -To strengthen the intersectoral partnership in the sphere of PMMB.
GES' activities started in December 2014 with the boarding of the first team of supervisors to visit doctors in remote areas, including those working in indigenous areas, in the state of Amazonas.Since then, the strategy was gradually improved and coverage areas were revised, always in agreement with the local teams of the supervisory institutions.
Although GES has logistic specificities, it is composed of the same professionals who work in the More Doctors Program, specified in the law that created it (Law 12871/2013 21 ): the "supervisor", a medical professional responsible for the continuous and permanent supervision of the participant doctor, and the "academic tutor", a medical teacher responsible for academic orientation and for the coordination of the supervisors' work.Up to the beginning of 2015, there was only one tutor responsible for GES in the state of Pará, who was in charge of all the supervisors who worked in that state in the Group's sphere.After the mission performed in November 2016, two tutors started to coordinate GES due to the large number of supervisors and to the logistic complexity required for planning the missions.Overall, between its beginning and the end of 2017, six tutors worked in GES, and two of them were still working at the end of this period.

Antecedents of GES in the state of Pará
The arrival of GES in the state of Pará did not happen immediately.It occurred in 2015, after successive meetings with the institution responsible for the academic supervision.At the time, Pará's territory was supervised by one single institution, Universidade Federal do Pará (UFPA), which could not supervise the entire territory because there were no local candidates to the position of supervisor interested in traveling to remote places in the state and because of difficulties in the formalities regarding MEC's financing of the supervisors' transportation.
The effectuation of the academic supervision, as provided by law, is MEC's responsibility, and this is governed by an Adhesion Contract signed by MEC and the supervisory institutions.Non-compliance with the law leads MEC to be held responsible, even if the supervisory institution is directly intermediating the action 27,28 .For this reason, when it was verified that there were regions assisted by doctors without academic supervision, it was necessary to arrange, with UFPA, GES' immediate entry in that territory, aiming to overcome the lack of visits to doctors working in remote regions of Pará.After approximately six months of meetings and negotiations, in March 2015 GES visited Pará for the first time, specifically the micro-regions of Baixo Amazonas, Carajás and Araguaia, including the indigenous area of Itaituba, which, up to the beginning of that year, had not received regular supervision visits.
Later on, a second supervisory institution -Universidade Estadual do Pará (UEPA) -adhered to PMMB and assumed a large part of the state's territory.
Initially, MEC identified areas that had not been receiving supervision visits and held a meeting with the first supervisory institution to select the areas that would be supervised by GES.On that occasion, it was agreed that the targets of this type of supervision would be some cities that were harder to access or those with poor conditions to maintain a supervisor, like the cities of the Altamira region and the city of Placas, as well as others in the regions of Carajás and Baixo Amazonas.Subsequently, UEPA became responsible for a large part of the remote areas, and GES was in charge only of the cities that this institution could not assume.

How the Special Supervision Group operates in Pará
PMMB resources are used to transport the supervisors from their places of origin to the pole cities.From those points, the Armed Forces take them to the place where the participant doctors work.
Until May 2017, the configuration of GES/Pará had five pole cities and eighteen municipalities, visited according to the following routes: The choice of the pole cities was MEC's decision, in agreement with the Ministry of Defense.The Ministry took into account the highways' conditions, the times of the supervisors' arrival and departure flights, the duration of the transport, and the amount of doctors to be supervised.This agreement demanded a visit from one of MEC's coordinators to the Army command in the city of Belém (the capital of Pará) to present the Group's objectives and align logistics for the supervisors' transportation and accommodation, after countless communication difficulties among the military levels, at the beginning of the activities in Pará.Therefore, the Armed Forces were in charge of the logistics that involved the choice of the transportation modality in each micro-region (air, land or river) and, in some cases, armed security.The type of transportation used in each situation is shown in the chart 1.Although the distances between the pole cities and the locus municipalities in a straight line are not significant, it is important to explain that the roads and riverways are often winding.Therefore, this distance does not correspond to reality regarding access difficulties.For this reason, distances are not usually measured in kilometers in Amazonia; they are measured in hours or even navigation days, in the case of river transport.The trips to Faro and Terra Santa, for example, last approximately thirty hours in river transport, although the former is 365 km far from the pole city and the latter is 203 km far in a straight line.The exact duration of the trip depends, many times, on the transport's speed.

Chart 1. GES/PA municipalities with pole city and type of transportation
Air transportation was used only at the beginning of the Group's activities.It was subsequently refused by the MEC's management team due to the precarious security offered by the only company that had airplanes available for charter.Thus, air travel was replaced by land and river transport, especially in the supervision of doctors working at the Special Indigenous Health District (DSEI).
It is important to highlight that, in the first year of GES, MEC was aided by the participation of the Brazilian Navy to transport supervisors to the city of Prainha, but in 2016 the Army assumed this task and also the transportation of the other supervisors.
Between 2015 and May 2017, GES/PA supervised approximately sixty-two doctors on a monthly basis, according to what is registered in the computerized system that MEC uses -Webportfolio/UNASUS.However, when we analyze the type of supervision, we find that four trips occurred in 2015 and five in 2016.In 2017, there was only one trip for face-to-face supervision, in March, due to difficulties faced by MEC as a result of changes in the macro-management of Brazil and in the technical teams, and also due to the scarcity of financial resources in the federal government that affected both ministries -Education and Defense.Thus, between its creation, in 2015, and the end of 2017, ten face-to-face supervisions were carried out.

The team's permanent education process
PMM follows the guidelines of the National Policy for Permanent Health Education, either by means of formal educational offers or by actions involving all the actors.It is important to highlight that GES allocated a space for the permanent education (PE) of supervisors, with MEC's and tutors' support, aiming at the qualification of the academic supervision and the consequent improvement in the pedagogical support the doctor receives.
Considering the variety of types of transportation and the times of the flights, the permanent education of the individuals involved in GES/PA was organized firstly in the city of Belém, which meant transporting each supervisor to that city after they supervised the doctors in the municipalities.From 2016 onwards, new adjustments were made and permanent education started to take place in two cities: Itaituba and Belém, demanding greater precision of the transportation conducted by the military.
The methodology of the permanent education encounters usually involved discussions of problems and specific situations observed during the supervision process, as well as debates on the regulation related to GES and to the More Doctors Program.Different events reported by the supervised doctors were also discussed in these meetings -in the majority of times, administrative issues not solved by the Ministry of Health that were registered by MEC Support and sent to the state authorities of the Ministry of Health.
Besides these face-to-face encounters, the team also participated in interactive expositions and in exchanges of ideas through web conferences planned and carried out by the tutors.

Challenges and possible solutions
The operationalization of GES in the state of Pará was a great challenge compared to the other special supervision groups mainly because of: a) the amount of pole cities that were created to reduce the distance to the places where the participant doctors worked; b) the size and geographical diversities of this Brazilian state, which demands more planning and articulation with the Ministry of Defense; c) communication difficulties with the Itaituba pole; d) difficulties in transporting supervisors to the Itaituba pole by commercial flight; e) the need of constant alignment with the partners of the Armed Forces, as each pole is coordinated by a different command; f) the need of armed security due to the violence that is usually seen in some places of the state; g) the fact that there have been four substitutions of tutors since the beginning of the Group's activities.
GES' action in Pará has always required, of MEC, a more attentive look and readiness to adjust each aspect.The main concern were the tutors, who, as mentioned above, were substituted many times.Due to the logistic changes that occurred, it was necessary to include, subsequently, a second tutor to lead the process.In addition, unpredicted events during the programmed face-to-face supervisions caused changes in planning that affected the Armed Forces and also tutors and supervisors.Among these events, we can cite a blocked highway due to a robbery in a nearby city, mechanical breakdowns in vehicles chartered by the Armed Forces, and a car accident on a highway involving a group of supervisors, without serious consequences.
In spite of all this, it was possible to perform the programmed supervisions in 2015 and 2016, and to consolidate spaces for the permanent education of the individuals involved.

Final remarks
The Special Supervision Group of the More Doctors Program in Pará, created to guarantee the local academic supervision of the doctors participating in the Project More Doctors for Brazil in that state, has been able to fulfil the six objectives present in resolution 28/2015 26 through a constant articulation among the Ministry of Education, the Armed Forces and the local supervisory institutions.However, due to difficulties concerning the logistics of its action, it is necessary that the supervisory institutions are constantly attentive so that their action remains regular and effective.
The Group is already considered a successful PMM experience because it was able to deliver the academic supervision according to the Program's guidelines and to the national health policies.The supervision experience of the Special Group team has contributed to consolidate the design of PMM regarding the emergency supply, and has shown that it is possible to perform the supervision with the quality and sensitivity that are necessary to assist the population that lives in remote areas of the Brazilian territory.In-service education with specificities respected by GES was only possible with a permanent education developed by a powerful team.It is expected that, with the rupture that occurred in Brazil's macro-management in 2016, the public health policies consider the SUS priority areas to inject capital and maintain the quality that primary care needs.
. Since then, several governmental programs have tried to mitigate the problem, like the Program of Interiorization of Health Actions and Sanitation (PIASS) in 1976, the Program of Interiorization of the Brazilian National Health System (PISUS) in 1993, the Program of Interiorization of Health Work (PITS) in 2001, the Qualification Program for Primary Care Professionals (PROVAB) in 2011, and, more recently, the More Doctors Program (PMM) in 2013 20 .The latter was created by means of Law 12871/2013 21 with the objective of improving the quality of the primary care provided for populations living in priority areas of the Brazilian National Health System (SUS).

Figure 1 .
Figure 1.Map with routes to the pole cities and municipalities -GES/PA Source: DDES/MEC and Google Maps