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Ciência & Saúde Coletiva

versão impressa ISSN 1413-8123versão On-line ISSN 1678-4561

Ciênc. saúde coletiva vol.21 no.9 Rio de Janeiro set. 2016

http://dx.doi.org/10.1590/1413-81232015219.17842016 

Article

The Mais Médicos (More Doctors) Program: panorama of the scientific output

Elisandréa Sguario Kemper1 

Ana Valeria Machado Mendonça1 

Maria Fátima de Sousa1 

1Organização Pan-Americana da Saúde (OPAS/OMS). Setor de Embaixadas Norte, lote 19. 70800-400 Brasília DF Brasil. elisaskemper@gmail.com

Abstract

Despite the progress achieved by the Primary Health Care and Family Health Strategy in the Unified Health System (SUS) challenges still remain with regard to the universality of access and the quality of services, one of the factors being the unequal distribution of physicians. The Brazilian Government established the Mais Médicos Program (More Doctors Program), in order to move forward in the provision, placement and training of physicians in the SUS. This study consists of a review of the literature of the Mais Médicos Program, in order to map and assess the scientific production on the Program, as well as summarize the findings and present the results of the analysis. Fifty-four publications were selected, which evaluate the Program in terms of effectiveness, analysis of the implementation process, the media and the statements of the actors and assessment of the legal and constitutional precepts. The criticisms and limitations found were also systematically analyzed. With respect to the analysis, evaluations of the Program are overwhelmingly positive, showing important changes in the work processes in services and training. The studies that show the Program as being an important instrument for the effective implementation of the right to health are highlighted.

Key words Primary Health Care; Mais Médicos Program; Access; Universal coverage

Introduction

The universalization of access and the provision of quality services are challenges faced by health systems, which seek strategies and policies that can overcome them and respond to the health needs of the population. Even in countries with universal systems and constitutional guarantees, as is the case in Brazil, in practice they face difficulties in achieving the Right to Health.

With the scientific support of the evidence, it is feasible to claim that countries with health systems organized on the basis of Primary Health Care (PHC) have better health outcomes, translated into lower costs of care, improved health, greater user satisfaction and the reduction of social inequalities17.

PHC should be understood as a level of basic and essential health care sustained by the principle of comprehensive care and based on scientifically sound and socially acceptable methods and technologies, ensuring full participation of the people8. It should be based on fundamental elements or attributes namely access and first contact, longitudinality, comprehensiveness and coordination of care, as well as individual attention focused on the family and the community9.

In Brazil, the empowerment of PHC has been a gradual process, with the expansion of the Family Health Strategy (FHS), which is the Brazilian way of organizing Primary Care in the Unified Health System (SUS), maintaining the principles of the SUS and supported on the attributes of PHC. In 20 years, the FHS has expanded its coverage from 5% to 60%7 and has had a positive impact on the health of the population, in addition to strong evidence showing that the results of the FHS are far superior when compared to the traditional PHC model in the SUS6,10.

Despite the marked expansion of the FHS in recent years, the ability to train physicians has not maintained the same momentum, nor have sufficient technologies been developed for adequate planning of human resources in health7. The lack of professionals with the appropriate profile for comprehensive care, combined with the shortfall and poor distribution of same are one of the main barriers to the universalization of access to health. New measures are also required to bolster the skills and competencies and the equitable distribution of medical professionals in the services11,12.

In this context, the Mais Médicos Program was launched in Brazil with the enactment of Law No. 12,871 of October 22, 2013, as the way to move forward in resolving PHC problems in the SUS, with measures to tackle the training, structure and supply of physicians in PHC services. The influx of foreign physicians to work in primary health care elicited a major negative reaction in the medical community with numerous ideological and legal disputes7.

Despite the criticisms, the Mais Médicos Program is more than the mere influx of foreign physicians on an emergency basis, as it proposes structural actions in the SUS7. These are aimed at expanding access and strengthening the work process in Basic Care, by intervening in the quality and comprehensiveness of care and planning of medical training. It is a program with a spectrum of actions ranging from the short to the long term; encompassing emergency and structural actions promoted in three areas: (i) expansion and enhancement of infrastructure of health units; (ii) emergency placement of physicians in unserved areas; and (iii) training of human resources for the SUS13.

In line with this government initiative, which aims to bolster PHC in the SUS by increasing access to and coverage of health services, among other measures, scientific research is required to evaluate this new and complex public policy as well as support decision-making and the enhancement of future strategies.

The Mais Médicos Program has not yet generated a large volume of published articles, especially for the evaluation of the effective results of the Program14. Due to the short time since the creation of the Program, the consensus is that many research projects are underway or recently completed and as yet unpublished. Thus, this study aims to map and measure the scale of the scientific production on the Mais Médicos Program, systematize the findings and present the results based on a critical analysis. The expected result is to add elements for reflection and discussion on this important strategy for the SUS.

Method

This is a review of the literature of the Mais Médicos Program, in order to provide a scientific overview and critical analysis of the literature selected. This study fits the definition of Vosgerau and Romanowski15 for a review of the literature, which consists of a way of mapping a field of knowledge, for the purpose of understanding the area's movements, configuration, methodological theoretical propensities and critical analyses indicating trends, recurrences and lacuna.

This review started with an electronic search in the Medline, SciELO, Lilacs and BVS/Bireme databases, using the term ‘programa mais médicos’ as key words. This was then followed by a search for other articles from the references cited in selected studies. The Knowledge Platform of the Mais Médicos Program (http://apsredes.org/mais-medicos/) was also used as a search tool by inserting the title of the research registered on the platform for the search in Google Scholar. This search was conducted between the months of January and February through March 20, 2016.

For the selection of publications, the criteria considered for inclusion were studies, articles and other publications mentioning the term Mais Médicos Program in the title or that had the program as its study focus and were published during the years 2014, 2015 and 2016. In total, 82 publications were found, though conference papers, those that did not generate articles and publications, or news reports in electronic media, blogs, institutional sites and social networks were excluded. After this screening process, 54 publications were considered for this literature review (Graph 1). In addition to these texts, a further 12 articles were selected to serve as a conceptual and methodological benchmark for the text.

Graph 1 Number of publications selected in this study based on the application of the exclusion criteria — Brazil, 2016. 

Results and discussion

A total of 54 publications were considered for the review of the Mais Médicos Program, 37 of which were in the format of articles and 17 were academic papers, divided into nine course completion works or dissertations and eight master's theses.

The revised texts were organized into six categories considering the main focus of the study or the results presented. The categories are: a) Analysis of the deployment of the Mais Médicos Program (15 publications); b) Effectiveness (15); c) Media (8); d) Limitations and criticisms (6); e) Training (5); and f) Legal/constitutional analysis (5) (Chart 1). The issue of effectiveness was divided into five sub-topics, namely: access, coverage and equity; comprehensiveness and longitudinality; changes in the work process and model of care; user satisfaction; and intersectoriality. Despite most of the publications featuring results in more than one area or topic, for purposes of this categorization, they were included in only one of them.

The areas that had the highest number of publications selected were those that included studies of the analysis of the deployment and effectiveness of the Mais Médicos Program. The hypothesis is that, as it is a recent policy, this justifies the number of studies that assess the Mais Médicos Program with respect to its deployment being higher than other areas and the need to evaluate it in terms of effectiveness, providing input for its legitimation and also producing evidence to back both the government's actions and provide answers to society.

In essence, the research set out to analyze and recount the historical process of the Mais Médicos Program and examine it in relation to compliance with the rules and from the perspective of social actors. It conducted comparative analysis, both with other countries and with the rules of recruitment and placement of the World Health Organization (WHO). It also involved studies of user satisfaction, on the broadening of access and coverage, with a focus on equity, on the impact on training and analysis of the main media channels in the country and legal studies in view of the constitutionality of the program and the right to health. It is significant that eight academic works were produced in areas other than that of health, namely in the area of law, administration, social sciences, philosophy, among others, pointing to an awakening of interdisciplinary interest generated by the Mais Médicos Program.

The outcome of the analysis of the publications, with a focus on the results thereof, will be presented in a systematic manner duly stratified by category below.

Analysis of the Deployment of the Mais Médicos Program

To begin a review of the deployment of the Mais Médicos Program, it is worth mentioning the factors that triggered the Program, which generated a political debate and opened a window of opportunity that turned into a social issue. The popular mobilizations in June 2013, the march of the mayors to Brasília in the same year and the inclusion of the decision makers at the political and institutional level, imbued with the purpose of choosing the alternatives for the most appropriate solution to the problem raised16,17.

The Mais Médicos Program deployment process was permeated by judicial disputes and ideological clashes, having been considered by medical organizations as an electioneering and poorly planned unilateral measure by the Federal Government7.

Even considering the hypothesis of a response to social mobilizations, authors have the gall to classify the deployment of the Mais Médicos Program as a top down public policy model, considering that the strategies and solutions come down from the top, despite acknowledging the efforts of the policy to attain the Right18.

August 2013 saw the arrival of the first foreign physicians within the scope of the Mais Médicos Program. The demand of municipal managers for physicians amounted to 15,460 vacancies, which were not filled by Brazilian physicians. One year after the start, the program had 14,462 physicians, working in 3,785 municipalities and attending a population of approximately 50 million people7.

Considering the range of the proposed objectives for the deployment process, one of the articles classifies the Mais Médicos Program as successful, since the call notices met their immediate employment goals. The number of Brazilian physicians who signed up to the Program has increased and the management is decentralized, but with well-defined roles and a clear and organized hiring structure19.

The Mais Médicos Program arises as a response to the legitimate need to enhance Primary Care and expand the coverage of the ESF, which had been experiencing slow growth (1.5% per year). It also set out to provide a more equitable distribution of medical services, with a focus on expansion and universalization of access to health and consequently impacts on training in care17,18.

In addition to the immediate placement of physicians, the Mais Médicos Program incorporates strategies to reorganize training in health in the country in an attempt to comply with the State's regulatory role in ensuring the Right to Health as enshrined in the Federal Constitution5,2022.

In terms of inherent potential, the Mais Médicos Program is configured as an effective transformative project for the future of the SUS. It is also an opportunity to redefine PHC and deploy the care model as it was designed by the FHS. This should contribute to the organization and development of health care networks and the transformation of the care model23,24.

It makes it possible to deploy the regionalization of medical training away from the major population centers and is configured as a strategy that permits new structuring of care teams, which may bring about an enhancement in the production of knowledge and new forms of care25.

From a comparative international perspective, the Mais Médicos Program is impressive in terms of its magnitude and scale to meet the demand of municipalities. It also has a marked differential in terms of ethics, since countries with the same proportion of physicians per capita or less than Brazil are not eligible26,27. With respect to the Mais Médicos Program (emergency placement), it is seen by the Cubans as a new cooperation model with a difference in relation to other medical aid or cooperation missions. This is due to the concept of ongoing education through training strategies throughout the in-service time on the project as well as many educational propositions28,29.

Effectiveness

Cover, Access and Equity

The lack of access to basic care affects a large part of the population in remote areas, which is vulnerable and on the outskirts of large cities, caused to a great extent by the shortage of medical professionals. The Mais Médicos Program contributes to ensuring the permanent presence of entire teams in high staff turnover regions, also allowing access and equity in services to historically deprived populations, such as the Quilombola (descendents of runaway slaves). Thus, it is possible to show that the Mais Médicos Program helped to reduce iniquities, serving the most underprivileged municipalities, which had the worst physician per capita ratios in situations of extreme poverty and with more health requirements2933.

In terms of coverage and effective access to health care and services, by placing medical professionals in teams the Mais Médicos Program brings healthcare to regions lacking in professionals and contributes to the growth required for expansion of the FHS34. Increased access is also witnessed by the increase in the gamut of services provided and the productivity of teams35.

It should be stressed that the coverage of the Mais Médicos Program is well qualified, since professionals comply with the recommended hourload, have adequate training to work in primary care and are in an ongoing process of in-service training and education35.

In numbers, we can see that the amount of Family Health teams in the country increased by more than 10% between May 2013 and May 2014. The population coverage of the Mais Médicos Program in the first 10 months was about 30 million people, especially in municipalities characterized as the 20% in greatest poverty36.

When one compares the years 2011 and 2013 with 2014, the population coverage of the FHS in the state of Pernambuco increased by 5%. When considering the parameter of the National Policy of Primary Care (NPPC) of 3,000 people per team, the Mais Médicos Program ensured access to an estimated population of two million people (June 2014). With the Mais Médicos Program, it was possible to deploy 25 Family Health teams in the municipality of Pelotas, Rio Grande do Sul37,38.

In terms of equitable distribution, it is on record that the number of municipalities with a shortage of medical professionals dropped from 1,200 in March 2013 to 558 in September 2014 (a reduction of 53.5%). With the placement of an average of 4.9 physicians per municipality (the highest ratio among the regions), 91.2% of the municipalities with shortages in the North in 2013 were provided for. Of the 143 participating municipalities in the state of Pernambuco, 103 (72%) are in a situation of poverty and these municipalities were allocated 58% of physicians of the Project17,29,37.

Of the municipalities covered by the Mais Médicos Program, around 400 had never had medical professionals in their midst. A case in point is the 34 Special Indigenous Health Districts (DSEI), distributed throughout the country, which had never had physicians and now have 300 professionals. For example, in 2013 the Yanomami had about 500 medical consultations, whereas the number of visits increased to seven thousand in 2014, with 15 Cuban physicians dedicated exclusively to the ethnic group (99% of the physicians who attend the indigenous population in the program are Cuban)39.

Integrality and longitudinality

The research shows that health actions and practices from the perspective of comprehensive care, as well as an expanded conception of the health-disease process, were identified in the Mais Médicos Program. The Program has expanded the provision and services from health promotion to palliative care and provided a closer bond and relationship with users which, in addition to strengthening the integrity, contributes to longitudinality (continuity of care over time) and is facilitated by the medical professional remaining in the team for a longer period of time32,39,40.

The attribute of longitudinality in PHC was identified by virtue of the fact that the physicians know the personal aspects of the life of their patients and this may mark the beginning of a long-term personal relationship. It became clear that a more open and communicative relationship between physician and patient is formed, as well as respect and a close relationship between the physician and the health team, which has boosted the comprehensiveness of health actions performed39.

Change of Work Process and Care Model

Like other health systems, the SUS faces the challenge of the triple burden of illness and the crisis caused by the mismatch between health conditions and a health system focused on providing care in acute conditions, which is reactive, episodic, focused on illness and without the active participation of users in care of their health2,5.

The inclusion of physicians in Family Health teams enhances and expands the capacity of intervention in view of the adoption of a model of care that attends health needs. It adds new practices and forms of care, brings new shared practices, strengthens the integration of the teams, while supporting the organization of services and contributing to the invigoration of Primary Care25,29,32.

The studies reveal evidence of an improvement in the work processes, such as the reports of managers and health professionals noting that the integration of the medical professional has expanded the diagnostic capabilities of the area's problems and brought more agility and continuity in the treatment of users. Changes were also observed in the quality of care since deployment of the Mais Médicos Program25,41.

With respect to care to specific population groups, one can highlight the improvement in the organization and delivery of services to the Quilombola, the strengthening of relations within the teams and greater coordination among professionals. Similarly, in an indigenous community, with the quality of the academic training of the foreign physicians, especially Cubans, it was possible to impact health care positively, with emphasis on the knowledge of medicinal plants and home visits with a more holistic approach33 42.

User satisfaction

In addition to demonstrating that users of the Basic Health Units are more satisfied with the medical care of the Mais Médicos Program professionals, concrete differences in the assistance provided by the Cuban physicians and the Brazilian physicians are highlighted. In many ways, the care of the Cuban physicians is considered by the users to be superior to that of the Brazilians, with emphasis on the question of listening, looking or paying attention and showing interest, education and respect43.

In one study, the high degree of user satisfaction considering the dimensions of “waiting time for scheduling an appointment” and “care during the appointment” was also observed29.

Results of a survey conducted by the Federal University of Minas Gerais (UFMG) and the Institute for Social, Political and Economic Research (Ipespe) in 2014 revealed that 85% of users evaluated that the medical care was ‘better’ or ‘much better’ after the arrival of foreign professionals through the Mais Médicos Program. Another 87% indicated an improvement in professional care during the consultation. Also according to the survey, 60% highlighted the constant presence of the physician and respecting working hours as a positive point and 46% said that access to appointments improved39.

Intersectoriality

Besides the nature of the Mais Médicos Program being intersectorial, since it began as a joint policy of the Ministries of Health (MOH), Education (MEC) and Planning, the fact that all actions of the Mais Médicos for Brazil Project, refer to joint actions of the MOH and the MEC, as stipulated in the Law, is highlighted44.

During the deployment actions of the Mais Médicos Program it is possible to identify the traits of intersectoriality. This was true in discussion of training geared to the SUS needs, in undergraduate courses and during residency, the opening up of new vacancies in courses of medicine and space given to Primary Care in discussions in the National Curricular Guidelines (DCN)44.

A clear example of intersectorial coordination is the strategy of integrated support to the Program implemented by the MEC. It has been presented as a coordinated management action that requires dialogue and collaboration. This brought the different levels of management and deployment of the Mais Médicos Program together and contributed to the improvement of Primary Care and the Brazilian Health System45.

Limitations and Criticisms

This review does not intend to present counter-arguments for the limitations and criticisms presented. As with other topics of this article, the idea was to systematize and present them to the reader, providing input for debate and reflection. It should be pointed out that the texts included on this topic — limitations and criticisms — are mostly texts on opinion, editorial or debate.

As a limitation, there is marked concern about the sustainability of the Mais Médicos Program, considered as a measure of a provisional and emergency nature. It runs the risk of merely becoming a short-term and high-cost stopgap model, with the same problems remaining after its duration period16,35.

In this respect, criticisms are also levied at the Mais Médicos Program being considered a response to structural problems of the SUS. The claim is that political and temporary responses, such as the Mais Médicos Program, are not sufficient to tackle structural problems, which require structural and long-term measures, with increased availability of resources for health as a whole, with investment in infrastructure, human resources, technology, among others20,35. For one of the authors, a solution suggested is the need to define a Personnel Policy for the SUS, which is consistent with the complexity of the health needs of Brazilians22.

One article suggests, more forcefully, that the Mais Médicos Program is a measure that goes against the grain of history, focusing on quantity to the detriment of quality. According to the authors, the opening up of new vacancies in courses of medicine and residencies and the sudden increase of physicians will not effectively contribute to the change in lifestyle of the population. It will also not resolve the issue of the equitable placement of professionals who, at the first opportunity, will turn to the private sector as a supposedly more rewarding professional alternative and contact with the major centers46,47.

Other aspects of the Mais Médicos Program are also criticized including: the commitment of professionals to practice medicine without proper training or cultural and linguistic adaptation; the amount paid to Cuban physicians; the restriction on the free movement of family members of Cuban physicians; the limit on the availability of migration of physicians; inadequacies in the implementation of supervision and mentoring activities; substitution of contracted physicians by foreign physicians; the allocation of physicians in already saturated areas; the contract format and the recruitment process; the extension of the courses in medicine and support to the expansion of private universities48,49.

Another point highlighted as a limitation is the fact that Brazil has a more complex environment than other countries, because together with the regional inequalities of distribution of physicians there is the underfunding of the SUS and fierce competition with the private sector. Moreover, with the deployment of the Mais Médicos Program the inability of municipalities to implement Primary Care with quality, sustainability and coverage of the population became evident. Only with the direct interference of the MOH was it possible to hire and place SUS physicians in a short time22,34,49.

Finally, in an article that analyzes the trends and elements that appear in the discourse linked to physicians and their representative organizations, it is possible to infer that the Mais Médicos Program might not be understood in its entirety. It transcends the emergency placement of physicians in deprived locations, as well as the misperception that the State, by fulfilling its role in regulating the structure, is interfering with the autonomy of the medical profession7.

Media

Since the official announcement, the Mais Médicos Program has generated intense debate in the media and social networks, being evident in the media coverage, public debate and pronouncements of the Federal Government and medical institutions. The media is an important tool for a particular purpose, as well as a key player in the implementation of public policy and can contribute to its failure or success50.

In general, analysis of these studies reveals a clear division of interests and positions and a strong political bias regarding the Mais Médicos Program. The majority prioritize the opposition between the representative bodies of the medical corporation and the Federal Government, the shallowness of content relating to the area of Public Health and the absence of the user's voice. Aspects relating to the nationality of the physicians, the validation of the foreign degree and professional registration were highlighted. They imply that the Mais Médicos Program is an electioneering policy and point to alleged flaws in the organization and the rules5153.

With respect to the studies that analyze the comments of physicians and representative bodies, one perceives a discriminatory position that discredits the foreign physicians and hints at the superiority of Brazilian physicians. However, there has been a change of position regarding the Cuban physicians as the program becomes consolidated. The results also point to the conclusion that Brazilian physicians have difficulty in accepting changes that might benefit a public, not only that of medicine, as a professional collective group5456.

One study examined the debate on the Mais Médicos Program on the Facebook page of the Ministry of Health and concluded that it may even represent a form of participation by circulating differences of opinion. However, this is not sustainable due to the lack of representation and legitimacy as only 0.18 % of the population commented on the posts57.

Training

An important objective set out in the law creating the Mais Médicos Program is the transformation of the process of training physicians in Brazil, in a clear attempt to concentrate training on comprehensive care and the needs of the population and the SUS. In essence, the State is finally attempting to restructure the entire concept of training in health17.

The analyses reveal a clear incompatibility in Brazil between the current model of medical practice and the universal and equitable access of the population to health services. They also point out that the Mais Médicos Program builds structural measures to improve medical training and attends the SUS legislation, which calls for new practices5860.

The changes that are stipulated in the Law refer to undergraduate courses in medicine, demanding the opening up of new vacancies and requiring the adaptation of the curriculums to the new National Curriculum Guidelines defined by the National Education Council (CNE). The law also stipulates changes in the residency requirements of some specialties, as it is necessary to do at least one year of general and community medicine.

Current public policies appear to be in line with the international recommendations to invest in the training of family physicians in sufficient numbers for a health system focused on PHC. Results show that the law establishing the Mais Médicos Program is a major evolution in management tools of human resources for health. They also herald changes and stricter application of the National Curriculum Guidelines for training physicians in the country, with an emphasis on Primary Care7.

With respect to in-service training, it has been seen that the Mais Médicos Program has excellent pedagogic potential58 and has contributed to the improvement of learning processes. Furthermore, the integration of school, service and the community has increased the level of satisfaction of medical students and their awareness of the importance of practicing in the community and the potential for learning in undergraduate courses in medicine61,62.

Legal/constitutional analysis

The studies that perform a legal and constitutional analysis of the Mais Médicos Program see the Program as a public policy which reaffirms the right to health from the perspective of ensuring legal and constitutional effectiveness and with the prerogative to improve the health levels of the population. The Program attends and is compatible with the Brazilian legal and constitutional framework and presents itself as an indispensable instrument of social efficacy to the right to health18,6365.

On the other hand, a single study was found, written while still under the Provisional Measure (MP 621/13) prior to the Law enacting the Mais Médicos Program, which alleges that the MP violates basic constitutional rules and hampers the proper provision of public health services. The author considers a Provisional Measure as a high-handed act of government, incompatible with what is expected of discretionary acts of Public Administration66.

Final considerations

The SUS moved forward in the process of reorganization of primary care, including the expansion of coverage and implementation of the FHS, as a proposal for a new model of care. However, challenges still remain to improve the quality of care and expansion of access towards universal access to health. In order to tackle one of the critical drawbacks of primary care, the Brazilian government proposed the Mais Médicos Program, considered as a series of measures to ensure the supply, placement and training of physicians for the SUS.

The Mais Médicos Program deployment process was fraught with debate and criticism regarding the way it was structured, its true effectiveness, and especially with respect to its sustainability, since it is a program linked to the Ministry of Health and is of a provisional nature. However, with the support of scientific research, it is possible to analyze it from the perspective of the positive changes that are taking place, the process of cooperation and exchange of knowledge between professionals and, in particular, user satisfaction.

With respect to the analysis of the publications selected, it is emphasized that, in general, the results of the Mais Médicos Program assessments are positive. This would indicate that satisfactory results are generated in relation to increased access, equity, user satisfaction and humanization of care. Innovative practices and changes in work processes were also identified, with emphasis on the practice of comprehensive care and longitudinality. The two-way exchange of knowledge between foreign medical professionals and health staff in the provision of care, contributing to the improvement of practices and in-service training and consequently in improved health outcomes should also be highlighted.

Results indicate that the Mais Médicos Program has a strong potential for reorganization of training in health, focused on the need of the country and the Health System, with the resumption of the state regulatory role in moving forward with this process, which is characterized as a response to a structural problem of the SUS.

From the standpoint of this article, the most important result is the evidence that the Mais Médicos Program is a public policy that complies with constitutional principles and is an important tool for ensuring the right to health.

Acknowledgments

Special thanks to Ariel Delgado Ramos for his support in the preparation of the graph.

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Received: March 28, 2016; Revised: June 30, 2016; Accepted: July 02, 2016

Collaborations

ES Kemper participated in the conception, framework, analysis and interpretation of the data and drafting of the article. AV Mendoça participated in revision of the article. MF Sousa participated in the approval of the version to be published.

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