| PMM |
Institutions |
Government structure - bureaucracy and centralization of the process |
“The Ministry da Health is tough, it’s a heavy bureaucracy, it’s a difficult process, it’s a country with a lot of rules, with a lot of difficulties, with a lot of situations. It’s obvious that in Brazil and in the Ministry, a centralized process in a country this size is not an easy operation” (BR_PM1). “In the Ministry of Health in recent years there has been a misguided re-centralization of health activities. The Ministry moved from a normative and policy-making role to a more operational role, and with highly vertical action in the local and state territories. I think this is critical, I this contradicts the framework of the Brazilian Unified National Health System (SUS)...” (BR_CS1). |
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Institutions |
Policy legacies - constitutional principle and previous programs |
“And at the same time we also reclaimed the Constitutional principle, where Article 200 of the [1988] Federal Constitution states that it’s the prerogative of the SUS to organize human resources training, so it provided the basis for the need, not only for programs, for example, to attract [health] professionals to a given location, but also to think of training, to think of continuing education, to think of various dimensions” (BR_PM2). “We have the understanding, for example, that it would not have been feasible to implement the PMM so quickly, or that in 9 months there would already be 14,000 physicians participating in the program, if it were not for the experience we already had with PROVAB. So this experience in the Ministry of Health to issue a national call for physicians, to allocate physicians in localities, to make the payments to these physicians, to supervise these physicians, and to monitor the development of the activities” (BR_PM2). |
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External Factors |
Presidential elections |
“...based on all the existing evidences, it was apparent that the main problem was the government’s need in the pre-election stage to have a star program, a program known in the health area (...) It was very attuned with the election calendar, which makes sense, since a lot of things happen for political reasons, and this case had a strong political relationship” (BR_IO). |
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Interests |
Actors that gained - governments (Cuba and Brazil), mayors of municipalities served by the PMM, civil society, and PAHO |
“...the President [Dilma Rousseff] wanted to guarantee the program, there was the population demanding more access [to healthcare] in the demonstrations, so there was this window of opportunity, the mayors were demanding, the President was supporting, and Brazil had the funds” (BR_Staff). “Referring to the demonstrations, ‘...that accelerated, made the President turn to us and say, that proposal you were developing, is it ready, or isn’t it ready?’. It’s ready. So let’s launch it” (BR_PM3). “One actor that gained a lot was PAHO, which got 50 million dollars and a lot of relevance with the [Brazilian] government” (BR_IO). |
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Interests |
Potential loser with the program - the medical profession |
“I think nobody lost, I don’t see it. I noticed that the Brazilian Association of Physicians and the Federal Board of Medicine initially mounted strong opposition (...) but later they realized that these doctors were forbidden from working outside of this program, so they weren’t going to be, and never would have been a source of competition (...) I think the program proved that there was something to gain for everybody” (BR_IO). |
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Ideas |
Scientific evidence - use in the policy process |
“Since 2011 when I’ve been in the Ministry, we use a lot of evidence to make decisions. For example, for us to discuss the PNAB, the President herself asked for scientific articles. She turned and said, look, I want some articles that show how the PNAB worked, is it really family health? What’s the impact? What is the best way to invest money in primary care?...” (BR_PM3). “...in mid-May 2013, the President convened a meeting with the medical associations, to hear these organizations about the problem the mayors were raising insistently, and to hear these organizations about the alternatives they saw (...) So they created channels to discuss the issue. The issue was the difficulty in acting as channels with proposals, because it was not about opening new medical schools, because it was not about brining doctors from other countries...” (BR_PM2). “One would say, there’s a shortage of doctors, the other would say there are doctors, but they’re poorly distributed. That actually both things are true, but one emphasized one thing and the other emphasized the other (...) But it all fell on deaf ears, it wasn’t a discussion. The Administration had already made the firm decision to bring doctors from Cuba, much earlier, at least a year before (...) And [medical associations] all over the world take the position against importing physicians from other countries” (BR_IO1). |
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Ideas |
Scientific evidence - mechanisms to promote the use of scientific evidence |
“These data served as backing, they had already been used before independently, I mean this feeling, this evidence already existed. So the policy was backed by this evidence that already existed, to be implemented (...) The studies were financed by the Ministry of Health and by the Observatory, in our case, and via PAHO” (BR_P4). “So the mechanisms varied. When we want something more quickly and the collaborator can present interim results, precisely to shed light and produce evidence for the policy, we usually fund directly. Because if we use a bidding process, the research may start today and it’s two or three years before you have any findings. And then the guy is going to write the article, and he doesn’t release [the findings] before the article. By the time the article is published, you’re no longer in office. When we want to do [the policy] to feed the decision-making process, we fund directly” (BR_PM3). |
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Ideas |
Scientific evidence - reasons for use |
“The second report was very interesting because it was used both by the CFM and the medical associations to prove that there was no shortage of physicians in Brazil and to say, ‘Look how unevenly physicians are distributed, how there’s a shortage of physicians.’ So if you look at the medical demographics, they serve as the basis for the position by the medical associations, against More Doctors, and it’s part of the PowerPoints and publicity materials, saying that the medical demographics prove, even give evidence, that there’s a shortage of physicians and that they’re needed. (...) So aspects that may be negative for one or the other political purpose are selected from the production and the scientific evidence” (BR_P1). “I think he promotes, like every policy-maker promotes. In principle the policy-maker does not decide on the basis of scientific evidence, he decides as a function of political pressure or the political demand that’s out there. Later he fine-tunes the response based on the scientific evidence, but this issue is triggered more by the perception, sometimes rather diffuse, of a certain reality, which is adjusted later by the evidence” (BR_P2). |
| Bilateral agreements |
Institutions |
Policy legacies - past experience with the bilateral agreement |
“According to estimates in 2008, it would take us approximately 7 to 10 years to have enough physicians for every Portuguese citizen to have a family doctor. This was especially difficult in some regions of the country where [physicians] didn’t want to go. And because there was already some international experience with this. Because in 2006, when I needed physicians to work only in medical emergency departments (...) I couldn’t get them in Portugal. Because in Portugal, in the physicians’ market, the supply and demand are turned around. (...) So there was an opportunity to sign an agreement with Uruguay to bring doctors to work in medical emergency departments” (PT_PM3). |
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Institutions |
Government structure - centralization of the decision-making process |
“...It was just me and two secretaries. So when I left there was nobody to deal with this. So I had to do everything, I hired the Camões Institute to teach Portuguese history. I hired Portuguese teachers… the entire policy was designed in the Ministry and thus with my work I answered directly to the Minister, so it was a lot easier, right?” (PT_PM3). |
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Interests |
Interests - political need and population’s need |
“It was political, because any government administration wants to say it gave doctors to everybody. And there had to be alternatives, as I said, there were only two [either increasing the list of users per physicians or hiring foreign doctors] (...) because there weren’t enough physicians” (PT_PM3). “In 2008 we were faced with this, we had done what was strategically adequate to solve the shortage of physicians, but we had a shortage of physicians because the strategic measures were going to take a long time to take effect” (PT_PM2). “Portugal’s objective was always the same. What they gave the country had to be consistent with what the countries wanted or needed” (PT_F3). |
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Interests |
Certain resistance to the strategy - medical profession |
“I couldn’t identify anyone that might lose (...) There’s always a little professional pressure, but I think everyone gained from this (...) And always based on an overall number, which is that Portugal has enough physicians by international comparison. Maybe it does. I’m not going to question that. Portugal may have [doctors] but there aren’t any in Odemira. I launched an admissions process, and nobody applied... I think my obligation as a policy-maker is to find a doctor that wants to go to Odemira” (PT_PM2). |
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Ideas |
Scientific evidence - did not contribute to the policy process |
“I don’t know what scientific evidence would be better than the absence of physicians interested in a place in a procedure that everybody knows? What could I do differently?” (PT_PM2). “From there, for us to base these policies on a sociological study, on a scientific study, I doubt that anybody will ever do one, and even generally speaking I think that policy-makers rarely base their decisions on scientific studies. I hate to say it...” (PT_EM1). |
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Ideas |
Scientific evidence - mechanisms to promote the use of scientific evidence (in shaping the policy agenda) |
“I commissioned the study, by a geographer who was very interested in spatial planning, and was thus very familiar with the country’s spatial situation in terms of where the health services are, where the health centers are, the population densities and the shortages of physicians, she worked extensively with those data and was writing a lot about it at the time, and she was particularly well versed on the subject. And it was a way to obtain a study quickly…” (PT_ PM4). |
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Ideas |
Scientific evidence - reasons for use |
“Policy-makers often understand scientific evidence from an instrumental perspective, that is, scientific evidence interests them to the extent that it corroborates a decision one has already made, and not exactly because it changes a decision just because it’s scientific evidence. Besides, many of these decisions are based on common sense and don’t require a lot of scientific evidence” (PT_EM1). |
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Source: adapted from Lavis et al.