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versão impressa ISSN 1413-8123
versão On-line ISSN 1678-4561
Ciênc. saúde coletiva vol.21 no.9 Rio de Janeiro set. 2016
Participation of small municipalities in the Mais Médicos para o Brasil (More Doctors to Brazil) Program in the macro-region of Northern Paraná
Doctor shortage is a constant problem in smaller cities and towns, which tend to be more vulnerable from a social and economic point of view, and located in geographically isolated areas. The goal of this study was to establish the share and characteristics of the small cities and towns in the macro-region of northern Paraná that subscribed to the Mais Médicos para o Brasil (PMMB) program. This is a quantitative study of 82 cities and towns using primary and secondary data. Results show that only a few of them (6.1%) had any adherence criteria, which was not an impediment for other cities and towns (75%) to adhere to the project. Cities and towns with over five thousand inhabitants, lower municipal HDI (Human Development Index), some adherence criteria and more geographically isolated, either from the main city in the region or the closest large or mid-sized city, tended to adhere to the PMMB. It is undeniable that the PMMB significantly reduced the uneven distribution of doctors in Brazil and the study region. However, the sustainability of this policy is linked to addressing other remaining challenges in the SUS system.
Key words Health management; Small cities and towns; Doctors; Healthcare policy
Geographically uneven distribution of doctors is an issue in several regions and countries. In Australia for example, the ratio of doctors per thousand inhabitants is only 0.9 in rural areas. The same is found in the United States, where 25% of doctors are foreign-born1. If we look at economically distressed regions, this shortage becomes even more critical, such as in certain countries in Africa and Southeast Asia2.
The shortage of doctors in Brazil is not a new problem. In the 1970s, the country had one doctor per 2,040 inhabitants and 1,895 municipalities had no doctor at all3. The situation improved over the years, and by 2009 there was one doctor per 676 inhabitants4. However, over 20% of the municipalities in Brazil have some sort of doctor shortage5. In Brazil, the problem is associated with uneven geographic distribution. In 2015, the doctor : inhabitant ratio in Brazil was 1.9:1,0006. This is lower than in the UK (2.7), Portugal (3.8), Spain (3.9) and Argentina (3.2)7.
Strategies to get healthcare professionals to settle in remote areas date back to 1976, with the program known as PIASS (Program to Take Healthcare and Sanitation to the Interior), followed in 1993 by the PISUS (Program to take the Unified Healthcare System to the Interior), and in 2001 by PITS (Program to take Healthcare Efforts to the Interior). The latest in this series of programs is PROVAB (Program to Value Basic Care Professionals)1,7–8.
In 2013, the National Mayor Front (FNP) launched a program entitled “Where's the Doctor?” They issued a petition demanding that foreign doctors be hired to work in locations where there was a shortage of doctors9. This petition, together with the WHO recommendations, resulted in the signing of law 12,871/2013, which created the Mais Médicos Program (PMM). Mais Médicos para o Brasil (PMMB) is the area of the program that manages the provision of such professionals.
Compared to previous strategies, PMM did not focus merely on providing doctors, but is actually comprised of three different spheres of action. In addition to creating new curricular guidelines for medical schools, it also seeks to increase the number of positions in medical school and residence, and enable contracting Brazilian and foreign doctors to work especially in municipalities with a lower than recommended ratio of doctors: inhabitants10. Where this program truly innovated in terms of providing doctors, was hiring foreign-trained doctors, as in addition to 1,846 Brazilian doctors, it included 12,616 doctors from 49 other countries, the majority of whom were from Cuba1.
All municipalities may subscribe to the program, so long as they meet the following criteria: Low/very low HDI, with 20% of the population living in extreme poverty, part of the semi-arid region of the nation, northern regions where there is a shortage, municipalities in the Jequitinhonha, Mucuri or Ribeira river valleys, highly vulnerable areas of state capitals, metropolitan regions and G100; Municipalities that subscribed to Provab, Special Native Indian Health Districts (DSEI), and municipalities with Basic Care coverage below the levels deemed necessary11.
The shortage is even greater in basic care, as the inserting doctors within overall family health is a major challenge, as these professionals are generally concentrated in major urban centers and hospitals9,12. In the smaller or more isolated municipalities, which are often in a situation of greater social and economic vulnerability, and where healthcare services are primarily constituted of basic care, this shortage is even more concerning5. Of the 1304 municipalities in Brazil with some degree of physician shortage in basic care, 875 (67.1%) are small, with fewer than 20 thousand inhabitants5. Doctor demographics show that the ratio of doctors to inhabitants in these smaller municipalities is quite a bit below what they are in large and mid-sized cities6.
In the macro region of northern Paraná, which is where this study was conducted, 82 of the 97 municipalities (84.5%) are small13. In light of this, and given the specificities of small municipalities in terms of doctors, it is essential to look into how they subscribed to PMMB to check the extent to which the program has achieved the goals proposed by the PMM. It is worth mentioning that quantitative studies of doctors in municipalities are required, as merely checking for the existence of such professionals in a given region or state does not demonstrate their true shortage in the smaller, more distant municipalities where it is harder to hire and retain professionals. Therefore, goal of this study was to establish the share and characteristics of the small cities and towns in the macro-region of northern Paraná that subscribed to the Mais Médico para o Brasil (PMMB) program.
This study is a section of a larger study entitled “Managing SUS in Small Municipalities in Paraná, as viewed from the Managing Team”. This study had financial support from Fundação Araucária – Unified Healthcare System Study Program: Shared Healthcare Management/PPSUS. The idea was to use a quantitative approach in a segment of the small municipalities that adhered to the PMMB.
The macro-region of northern Paraná has 82 small municipalities (20,000 inhabitants or less)13, a characteristic that does not favor doctor retention, either because of the distance to larger urban centers, or for reasons related to increased social and economic vulnerability. These municipalities are grouped into five Healthcare Regions (Figure 1).
Chart 1 shows the small municipalities in these regions.
|16th HR||17th HR||18th HR||19th HR||22nd HR|
|Bom Sucesso||Alvorada do Sul||Abatiá||Barra do Jacaré||Arapuã|
|Borrazópolis||Assaí||Congonhinhas||Carlópolis||Ariranha do Ivaí|
|Califórnia||Bela Vista do Paraíso||Itambaracá||Conselheiro Mairinck||Cândido de Abreu|
|Faxinal||Centenário do Sul||Nova Anérica da Colina||Guapirama||Godoy Moreira|
|Grandes Rios||Florestópolis||Nova Fátima||Jaboti||Jardim Alegre|
|Kaloré||Guaraci||Nova Santa Bárbara||Japira||Lidianópolis|
|Marilândia do Sul||Jaguapitã||Rancho Alegre||Joaquim Távora||Lunardelli|
|Marumbi||Jataizinho||Ribeirão do Pinhal||Jundiaí do Sul||Manoel Ribas|
|Mauá da Serra||Lupionópolis||Santa Amélia||Pinhalão||Mato Rico|
|Novo Itacolomi||Miraselva||Santa Cecilia do Pavão||Quatiguá||Nova Tebas|
|Rio Bom||Pitangueiras||Santa Mariana||Ribeirão Claro||Rio Branco do Ivaí|
|Sabáudia||Porecatu||Santo Antônio do Paraíso||Salto do Itararé||Rosário do Ivaí|
|São Pedro do Ivaí||Prado Ferreira||São Jerônimo da Serra||Santana do Itararé||Santa Maria do Oeste|
|Primeiro de Maio||São Sebastião da Amoreira||São José da Boa Vista||São João do Ivaí|
|Total: 14 MPP(82,3%)||Total: 17 MPP(80%)||Total:18 MPP(86%)||Total: 18 MPP(78%)||Total: 15 MPP(94%)|
The adherence criteria used for the study were IDH, registration in PROVAB, or being a DSEI, as other criteria are not consistent with the reality of the study region.
The secondary sources of data used in this study were data from DSEI, obtained from the Ministry of Health State Department of Indigenous Health (SESI), population data and Human Development Index (IDH) from the IBGE (Brazilian Institute for Geography and Statistics) website, and data on PROVAB membership, taken from the Ministry of Health PROVAB website. Primary data was obtained by interviewing the administrators of all 82 municipalities, regarding adherence to PMMB and the number of doctors in the project.
Thus, the study variables were: population, IDHM, being part of DSEI, being a PROVAB member, adherence to the PMM, number of professionals in the program and distance (km) to the municipal seat and distance (km) to the closest large city. The data was collected between November 2014 and June 2015, and placed in an Excel database. The data was analyzed with the support of Epi-Info for Windows, version 3.5.4.
The technical aspects governing this survey are described in Resolution 466/1214. This study was approved by the Ethics Committee for Research Involving Human beings of Universidade Estadual de Londrina.
We analyzed 82 MPP in the macro-region of northern Paraná, only 5 of which (6.1%) fulfilled the criteria for priority adherence to PMMB. Five of them fulfilled two criteria: part of DSEI and registered with PROVAB. Despite the fact that most of the municipalities do not meet the criteria in the law, over half of the small municipalities (62 or 75.6%) in the region adhered to PMMB (Figure 2).
On a regional basis, over half the regions adhered to the PMMB. The largest rate of adherence, or 83.3% of the small municipalities, was found in the 19th HR, and the lowest, or 59% was found in the 17th HR (Graph 1).
Regarding the number of physicians, most of the municipalities (49 or 79%) received a single doctor, and 8 (12.9%) received two. Five (8.1%) received between three and four doctors.
In terms of the small municipalities adhering to PMMB (Table 1), those with average IDHs had the highest rates of adherence.
|Characteristics||Adhered to the PMM|
|5,000 or less||19||65.5||10||34.5|
|Distance to the Healthcare Region seat|
|30 km or less||7||53.8||6||46.2|
|Over 61 km||35||83.3||7||16.7|
|Distance to the nearest large city|
|30 km or less||10||58.8||7||41.2|
|Over 61 km||25||80.6||6||19.4|
The largest rate of adherence to the PMMB was found in municipalities with 10 to 20 thousand inhabitants. Similar rates were found in municipalities with 5 to 10 thousand inhabitants, but the rate of adherence was far lower in municipalities with fewer than 5,000 inhabitants.
All of the municipalities that fulfilled the PROVAB and DSEI criteria in law 12.871/2013 adhered to PMMB (Table 1). In other words, in northern Paraná, the project met its goals in terms of adherence of municipalities meeting these criteria. It is worth reiterating that municipalities fulfilling the adherence criteria in the policy were located in remote regions and were socially and economically vulnerable.
Another characteristic of the municipalities with higher adherence rates were distance, either to the municipal seat or to the closest large or mid-sized city.
Concerning the municipalities that did not adhere to the PMMB, this may be related to political reasons, high IDH, or proximity to large urban centers.
It is important to point out that although this is a region where the adherence criteria are not very present, this was not an impediment for major adherence to the program. This leads us to infer that doctor shortage is not a problem only in areas where adherence criteria are more prevalent, but in other regions as well. The SNEPFPAS Seminar (National Seminar on the Shortage, Provision and Retention of Healthcare Professions in Remote and Vulnerable Areas) showed that doctor shortage and uneven distribution was not only a problem only of municipalities that fulfill the adherence criteria12. A study by the EPSM (Market Signal Survey Station) of the Observatory of Healthcare Human Resources shows that in the state of Paraná, 89% of the municipalities have fewer than 0.66 primary care doctors per 1,000 inhabitants. In the study macro-region, 80.4% of the municipalities were below this. If we look at small municipalities, 78% had fewer than 0.65 doctors per 1,000 inhabitants5. This data confirms the shortage of doctors in small municipalities. Corroborating the results of this survey, a study in metropolitan Recife shows that most of the problem retaining doctors in the Family Health System is related to the small number of inhabitants15.
Around the world, nations are seeking mechanisms to ensure universal healthcare and strengthen systems to provide the healthcare needs of their population. This goal is perfectly aligned with providing healthcare personnel, including doctors1. Santos et al.9 found that healthcare teams that do not include a doctor have limitations, as doctors play a unique role, as do other professionals, all of which are essential to provide care based on the principle of comprehensive care.
However, one must bear in mind that the lack of attractions in the regions with the lower social indicators and inadequate working conditions, including too many hours and poor compensation, make it hard to retain doctors. Ney and Rodrigues16 stress that this difficulty is found primarily with basic care doctors, and mentions a number or reasons, such as inadequate human resources, precarious employment bonds, overload, high turnover, dissatisfaction with the working condition and environment, and the absence of city career and compensation programs.
There is a study that shows that greater compensation may not be sufficient to offset the hardship of more isolated areas, where the professionals and their families will have a poorer quality of life. In light of this, a possible appeal is to formulate public and macroeconomic management policies to promote the development of regions that are more isolated and/or more socially and economically vulnerable, thus contributing to correct some of the elements that are at the cause of the poor doctor distribution in this country6.
Regarding adherence by region, the lowest rate was in the 17th HR, which also has the largest number of people living in small municipalities (18.6%). Furthermore, it has a high level of socioeconomic development and service offerings17. Of the five regions, the 17th has the largest number of healthcare establishments and the largest concentration of medium and high complexity services18,19. It makes sense that this region had the lowest adherence to the PMMB, as has more of the characteristics that attract doctors, without the need for a specific policy, as it is fair to assume that doctors would rather remain in areas with a higher GDP, where there are more opportunities for continued education and better infrastructure and working conditions8,20–21. However, even in this region, over half of the municipalities adhered to the PMMB. This is consistent with the SNEPFPAS report, which describes doctor shortage even in municipalities that have the financial resources to hire such professionals12.
On the other hand, in the 19th HR, 51.6% of the population lives in small municipalities of only moderate socioeconomic development. In general, compared to the other regions the 19th HR had the highest infant mortality rates (until 2006), or 20.4 per 1,000 live births18. Locations with high levels of social vulnerability and infant mortality tend to have poorer socioeconomic conditions and a greater shortage of doctors. Thus the policy to provide more such professionals is an interesting option for these towns, allowing them to meet a significant need20.
One of the realities of these towns, especially the smaller ones, is that they are not considered independent managers, despite the fact that the State has not been able to provide them with the minimal amount of social and economic infrastructure to ensure its inhabitants the right to healthcare. This is directly related with retaining professionals, as it affects the location's ability to pay wages and offer good working conditions8.
For most small municipalities, only a single doctor registered with the PMMB. In light of this, one gathers that for this region the project was important, complementing family health teams that lacked doctors. According to Santos et al.9, in hard to reach municipalities, Family Health (ESF) did not have doctors, limiting their ability to provide comprehensive care. A significant contributor to the non-sustainability of these teams is the high turnover of healthcare professionals, in particular doctors, who normally remain in these teams for just one year12,22,23. According to Capozzolo24, work overload in family health teams, structural issues such as a shortage of drugs and materials, as well as no support from other levels of care, contributes to the insecurity resulting from professionals who are poorly qualified to be general practitioners, leading to high turnover in Family Health Strategy (ESF) teams.
The PMMB is more prevalent in the municipalities with lower IDH, which is important in terms of providing doctors as regions with poorer socioeconomic conditions tend to experience a larger shortage of professionals20.
It is interesting to note that the municipalities with the smallest numbers of population levels were also more reluctant to adhere to the PMMB, even though Scheffer et al.6 claim these locations have the lowest doctor to inhabitant ratios. However, given the difficulty in retaining doctors in smaller municipalities, those that have only a single ESF team have an advantage, as the city administrator need only provide a single professional, which is not the case in municipalities with 5 to 20 thousand inhabitants. Given the average number of teams per population stipulated in the National Basic Care Policy, these would need up to seven doctors to cover all of the population25. It is assumed that this is the reason for the higher adherence of these municipalities to the PMMB.
All of the small municipalities that met the priority criteria for adherence did in fact join the PMMB. It is worth pointing out that it is expected that municipalities that meet any of the criteria will adhere to the program. Among other advantages, it allows them to transfer the not inconsiderable financial burden associated with hiring doctors to the federal government. This is especially important as the autonomy that decentralization granted to municipalities did not bring with it any increased ability in public administration8. According to Mendes26 and Silva27, over 50% of the municipalities in Brazil did not collect enough in taxes to cover their administrative and legislative expenses.
Those furthest from larger urban centers tend to be more in favor of adhering to the PMMB. According to Scheffer et al.6, regions that are further from major urban centers tend to have more problem attracting medical professionals. For Póvoa and Andrade21, this is because they generally offer limited jobs and little outlook for professional growth for the professional or his/her spouse. Furthermore, doctors tend to remain in cities that offer medical schools and residence programs, or at least in locations close to such centers28. The program had a positive impact on the region, reducing inequalities, particularly in terms of providing medical professionals in locations further from major urban centers.
Finally, it will not be a mere policy that will resolve such a complex and chronic problem that extends beyond medical professionals. There is no single or isolated solution. Interventions that articulate federal, state and municipal administrations, funding, changes to the professional training of healthcare professionals and regularization of labor and employment in healthcare are also required12.
It is undeniable that the PMMB significantly reduced the uneven distribution of doctors in Brazil and the study region. Doctor deficit is a problem even in regions lacking any of the adherence criteria, meaning it is a problem even in municipalities in good socioeconomic conditions that are not located in remote regions. From this, we infer that in the smaller municipalities, regardless of their location or social situation, are not favored when doctors choose where to work. In light of this, the PMMB mobilized municipal leaders to address the shortage of doctors in their locations, even if they do not meet the adherence criteria.
In the case of Brazil, where healthcare is the right of every citizen and the duty of the state, and where there is a unified system that proposes universal, comprehensive and equal care, reducing the uneven distribution of doctors, especially in the more isolated regions, is essential. Because of this, the urgent need to effectively grant citizens the right to universal and comprehensive healthcare justifies the creation of a public policy in the form of a Provisional Measure. This policy is consistent with SUS, to the extent that increased population access to doctors as a professional category, but also to a number of healthcare services and measures that depend on a doctor, helping these professionals settle in locations where there were none, or where turnover is high, so that they may become more deeply involved with local healthcare needs and create a bond to the community.
However, one must bear in mind the insufficient funding of SUS and poor working conditions remain a reality, so one must think beyond providing professionals on an emergency basis, and formulate policies to ensure that SUS is sustainable, and offer good working conditions for all of the professionals involved. Furthermore, policies to provide professionals will only be effective if they bring with them a commitment to changing the working process. This requires mutual learning between schools and services, trying to transform the local healthcare reality and the outlook for continued education. It is also important to continue to articulate across federative units, to implement state regulatory policies and constantly monitor and improve the Mais Medicos program.
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Received: March 06, 2016; Revised: July 04, 2016; Accepted: July 06, 2016