Ideas, images and beliefs in the production of public policies: the case of the More Doctors Program

Abstracts

This paper analyses the perspectives of the candidates for elective positions at the federal and state levels during the election process in 2014, regarding the More Doctors Program, presented by print and online commercial media vehicles, identifying ideas, images and beliefs related to this public policy. Mapping of the perspectives of the candidates aimed to identify senses and meanings of the program and outline the description of problems and solutions regarding the provision of health professionals under the Brazilian National Health System. The data showed that the subject of emergency provision of physicians went beyond the subsystem or field of health care and became part of the political agenda. Both candidates who supported the program and those who criticized it publicly stated that it was a necessary program and a strategy to which they would be committed. The program has greatly expanded the visibility of the health sector agenda.

More Doctors Program; Primary Health Care; Provision of health professionals; Media

O artigo analisa as manifestações dos candidatos a cargos eletivos de âmbito federal e estadual, durante o processo eleitoral do ano de 2014, quanto ao Programa Mais Médicos, presentes na mídia comercial impressa e on-line, identificando ideias, imagens e crenças sobre tal política pública. Um mapeamento do posicionamento dos candidatos objetivava identificar sentidos e significados sobre o programa, explicitando a descrição de problemas e soluções acerca da provisão de trabalhadores no Sistema Único de Saúde. Os dados obtidos demonstraram que o tema do provimento emergencial de médicos extrapolou o subsistema ou campo da Saúde e foi assumido como agenda no sistema político. Tanto os candidatos manifestamente favoráveis ao programa quanto aqueles que faziam críticas expressaram publicamente a imagem de um programa necessário e uma estratégia com a qual estariam comprometidos. O programa ampliou muito a visibilidade da agenda setorial da Saúde.

Programa Mais Médicos; Atenção Básica; Provimento de Profissionais; Mídia

El artículo analiza las manifestaciones de los candidatos a cargos electivos en el ámbito federal y de los estados, durante el proceso electoral del año 2014, con relación al Programa Más Médicos, presentes en los medios comerciales impresos y on-line, identificando ideas, imágenes y creencias sobre tal política pública. Un mapeo del posicionamiento de los candidatos tenía el objetivo de identificar sentidos y significados sobre el programa, explicitando la descripción de problemas y soluciones sobre la provisión de trabajadores en el Sistema Brasileño de Salud. Los datos obtenidos demostraron que el tema de la provisión de emergencia de médicos sobrepasó el sub-sistema o “campo” de la salud y fue asumido como agenda en el sistema político. Tanto los candidatos manifiestamente favorables al programa, como aquellos que hacían críticas, expresaron públicamente la imagen de un programa necesario y una estrategia con la que estarían comprometidos. El programa amplió mucho la visibilidad de la agenda sectorial de la salud.

Programa Más Médicos; Atención Básica; Provisión de profesionales; Medios

Introduction

This paper mapped and analyzed views about the More Doctors Program (MDP) held by candidates for elective positions in the executive and legislative branches, at the federal and state levels, found in print and online commercial media vehicles during the 2014 election process. The objective as to identify converging and conflicting ideas, images and beliefs, considering media as a notable resource in contemporary politics, mainly because of their strong and comprehensive ability to produce senses and meanings for issues in dispute¹. The MDP was created in a context of questions about the role of public power in the regulation of professional work and training², since it was one of the initiatives of the federal administration of the Brazilian National Health System (SUS) to strengthen the primary healthcare system.

The MDP includes investment in infrastructure in basic health units, expansion of university courses in medicine, curricular and extracurricular alterations in medical undergraduate and specialization (residency) degrees, and emergency provision of physicians in vulnerable areas^2,3-5. The justification for implementing this policy was based on healthcare expansion in the context of the National Primary Health Care Policy (PNAB)⁶. One of the obstacles to this expansion was the provision and establishment of health professionals, particularly physicians, in remote and more vulnerable areas^4,7.

The transformation processes in public policies, the interests and projects of the social actors involved in public policies⁸ have an impact on the ideas, images, and beliefs that guide these processes in terms of what problems and solutions should be addressed by actions of the state. These ideas, images, and beliefs not only help create technical formulations in the decision-making areas of public policies, but they also have a role in the development of agendas and innovations brought to politics^9,10. The public context in which policies are formulated and implemented also influences their construction. The analysis of public policy implementation supports the understanding of those processes and the results they achieve and strengthens the need for monitoring and evaluation for their follow-up¹¹. Election processes and their results are considered relevant for the configuration of public policies, since changes in government coalitions create possibilities for reformulations of actions of the State^12-14.

The assumption that people give limited attention to public policies has defined various approaches to policy analysis. It is thought that people are not able to remain attentive to all issues at all times^12-14. To promote policy changes and reformulations, the issues should be included in the agenda of the actors¹⁵. Media channels have a role in the definition of agendas for public discussions and consideration. News vehicles draw the attention of the general public to some issues regarding “reality” that have been previously selected, and this is considered the first step in the formation of public opinion¹⁶. During the election process, some themes are incorporated into the agendas of the candidates, who assume positions in relation to what they consider to be problems and present their views in order to influence actors and achieve success in the election.

The purpose of mapping the views of candidates regarding the MDP was to explain the parameters used by the candidates to present problems and solutions regarding the provision of health professionals, indicating the direction for this public policy, since the candidates are skilled strategic actors, and they dispute the coordination of actions of the state. A second objective was to identify the main ideas disseminated, the images and beliefs, and the results in the formation of senses and meanings about this theme.

Methodological and theoretical design of the analysis

Reports addressing the MDP were identified in 137 commercial media vehicles in Brazil from July to October 2014, and later analyzed. The search was performed daily during this period by robot clipping by news agencies that provide services to the federal government, using the keywords Programa Mais Médicos (More Doctors Program –MDP) and Mais Médicos (More Doctors), covering online and digital media. Noivo 10.0 was used for data organization and treatment. The views of candidates for president, governor, senator and federal and state representatives were selected.

Content analysis aimed to highlight the themes and views expressed by the candidates that were disseminated in the media messages. These analyses are intended to show trends for major themes¹⁷. The views of the candidates were selected from the database, which included all news published in the period and was classified according to the views expressed by the candidates. From this selection, the general data of the corpus was extracted and the content was inductively analyzed. Qualitative analysis of the content was conducted to identify the ideas, images, and beliefs expressed by the candidates. This was because themes that are, or are not, considered as problems and the various possibilities for solutions are constantly in dispute when conducting public policies. There are always divergences in the processes of defining the public agenda, which raises questions about how and why some problems are incorporated into the agendas of various actors and others are ignored^13,14.

A key issue in understanding public policies is their relationship with stakeholders – individual and collective actors who defend certain ideas and views regarding politics. A public policy is the result of a systematic process of negotiation and interaction of state actors and society groups – market and social groups¹⁸. The social actors who participate in decision-making processes, with their interests, projects and different governing systems^8-10, use different formulations to explain problems. Then, in ways that are minimally coherent with these explanations, propose solutions, objectives, and the methods to achieve them⁸. They also justify and legitimize the proposed policies, presenting them as solutions to social issues that they claim are in need of action by the state⁹.

To properly understand the process of political agenda definition and disputes about projects and formulations, it is necessary to use a matrix analysis that considers more than just the actions of actors that are justified by their explicit or latent interests. Some studies and approaches have shown the importance of understanding the role of ideas in the development of agendas and policy innovation, considering the political process itself in its symbolic and interpretative dimension¹⁰. In this approach, the analytical task is to identify how certain social phenomena become policy problems, and comprehend how the understanding of these problems emerges to guide the policy definition process. It is necessary to analyze the symbolic aspects of collective action to consider the contributions of ideologies and worldviews, as well as dialogical, not just instrumental, interactions¹⁰.

The complexity of modern societies and the inability of individuals to cover all themes at all times (assumptions of limited attention and rationality of individuals) influence the processes of interaction and negotiation among the actors. The way information and the attention of actors are processed becomes a relevant issue in the analysis of public policies and the role of media in the society^12-14,16. Media vehicles have a significant role in public agenda definition and suitability of issues. Regarding agendas, media select the aspects of reality that will be in public debates, significantly influencing which themes and issues will be thought about by the actors¹⁶. Media also weigh in on the suitability of issues, producing narrative schemes that allow actors to interpret events¹⁹.

In the case of the relationships among the state, society and media actors, dual directionality is highlighted, since actors respond to the media agenda and seek to influence it. The actors seek public visibility that gives them political capital that can be transformed into political status and the ability to gain advantages in negotiations and interactions about public policy content. In the case of candidates, the intention is to change this capital into votes¹⁹. Therefore, media are actors that influence public policies, offering visibility to some actors and ideas, as well as an arena that shows disputes of state and society actors.

The limits of attention and rationality of individuals are exceeded in actions by the state, beginning with institutional structures that are divided for the parallel processing of several issues. Through the organization of subsystems or strategic fields of action, it is possible to address different public policy themes simultaneously^12,20. In the case of federative units, top executives and legislative representatives are at the center of the “big politics” that influence plans, programs, and actions in each government dimension, recognized as the arena in which issues are addressed in series, that is, some themes are periodically incorporated into the agendas. Issues that go beyond the subsystems or fields of strategic action are incorporated into the agendas and have greater potential, but there is no guarantee they will become objects of change¹³.

The theme of the provision of health professionals is not a new topic in the agenda of the healthcare sector, since several initiatives have already been formulated within the scope of SUS. These initiatives have been characterized by sectoral conduction with limited effects on the problem: lack of physicians to work in primary health care⁷. The inclusion of this issue in the agenda of the Presidency of the Republic and the federal legislature in 2013 enabled the formulation of a specific program and the adoption of normative changes in the regulation of physician training and work; institutions were created and resources were allocated for their implementation^2-4.

Disagreements regarding the way to describe and understand politics are visible when proponents and opponents defend different perspectives. The identification of ideas, images, and beliefs on media vehicles by candidates for elective positions shows the convergent and conflicting issues in the MDP implementation process. Candidates for state leadership are considered to be actors who act strategically to structure and sustain social spaces through the creation of shared meanings and political coalitions that provide a common and viable existential ground. The indissociability between material/instrumental and existential motivation is considered in such a way that strategic actors act both to sustain their interests and instrumental advantages and build meaningful worlds for themselves and for others²⁰.

Strategic actors, such as candidates for elective positions, need to be able to induce the cooperation of others. Social ability is the ability of individuals or groups to mobilize people using ideas about the world and themselves, identify preferences and the environment, and define lines of action. Some people have a better ability to shape meanings and generate senses that mobilize collective action²⁰. Candidates for elective positions are, therefore, considered strategic actors who use already-existing shared meanings and collective meanings and seek to build new worldviews, seeking to obtain voluntary cooperation of others through the cognitive, empathic and communicative dimensions²⁰.

Ideas (the cognitive dimension) express policy content and proposed solutions to problems¹⁴. Beliefs (the empathic dimension) about general ontological principles of the human condition and political or instrumental preferences¹² express meanings and symbols shared by the actors about the world and themselves²⁰. Images (the communicative dimension) refer to empirical information and emotional resources that synthesize public and private identities¹³. In this approach to policy analysis, the knowledge variable emerges and is highlighted by superseding approaches in which interests exclusively explained the relationship between individuals and groups and the results of state actions²¹. Then, in this analysis, the reconciliation of ideas, beliefs and images is a more useful path^22,23.

During the study period, from July to October 2014, the MDP was in the implementation phase. The objectives and scope of the program, which were discussed during the analyzed period, had already been defined by law. The MDP was instituted by Law no. 12.871/2013³; it was preceded and complemented by policies whose objectives included consolidation of planning, implementation, deployment, evaluation, and monitoring processes, for improved access and qualification of health care, mainly primary health care, which was a priority axis of the Ministry of Health for the implementation of SUS principles^2,3-6. In 2014, the MDP allocated 14,462 physicians to 3,785 municipalities and 34 indigenous districts. Of these professionals, 80% were Cubans hired through the Pan American Health Organization (PAHO)⁴.

The emergency provision foresaw the allocation of professionals to work in primary health care in regions with greater need, vulnerability and difficulty in attracting and retaining health professionals. The program established an order of priority in which jobs would be offered first to Brazilian physicians and foreigners with a record of professional practice in the country (registration in regional medicine councils). Brazilian physicians who graduated abroad were in second place, even though their diplomas would be revalidated in Brazil. Third place was assigned to foreign physicians who graduated abroad, and were qualified to practice medicine in their country of origin, but without their diplomas revalidated in Brazil. Finally, the law authorized a cooperation agreement with an international body. Based on this rule, Brazil signed a cooperation agreement with PAHO which, in turn, established a cooperation agreement with the Cuban government, allowing the transfer of physicians who worked for the Ministry of Public Health of Cuba, and who had training and experience in international missions.

Views of candidates on the MDP

This paper is the result of more extensive research about the media agenda related to the MDP. This study showed that, during the analyzed period, the candidates for elective positions were the actors who had the most opinions about the program in the analyzed vehicles. The construction of shared meanings and senses among the collective actors, which is the objective of the candidates for elective positions and strategic actors, presents nuances that contribute to the understanding of the convergences and disputes related to the MDP and the provision of professionals. Table 1 shows the main ideas in the unfavorable views of the MDP, which represented the minority of candidate views.

Table 1
Ideas, beliefs and images related to the MDP, referred to by candidates who did not support the program.

Ideas	Beliefs and Images
“The country does not need more physicians.”	There is no shortage of physicians. Physicians are not the problem.
“We have to make investments in hospitals, have the necessary equipment that a hospital requires, for example.” “We have to equip the hospitals, give structure to physicians so that they can perform their work.”	The insufficiencies are in infrastructure of services, especially in hospitals. The quality of health care is linked with hospitals, and health care depends on hard technologies.

• Source: Primary data of the study.

The candidates who did not favor the program questioned having the whole solution generated in politics. They reinforced their belief that hospital centrality as the model of health organization. A convergent idea in different positions was the insufficiency of physicians as a contextual problem of the Brazilian health system, as illustrated in the following statements:

The More Doctors (program) became a necessity. We plan on keeping the program.

We need the More Doctors (program) to have more physicians.

Brasil had a large shortage of physicians; some regions had no physicians, the More Doctors (program) was a wise decision.

Believing that the problem is lack of physicians, whether in specific places or in general, is relevant, since it leads to solutions. That was one of the main issues discussed in the formulation phase of the program. Some actors, in particular representatives of the medical community, argued the issue was a different problem, and that the number of physicians in Brazil was sufficient. The view of the candidates consolidated an image that is expressed in the program identity, that is, the need for and relevance of more physicians in Brazil. Table 2 shows the main criticisms of the MDP.

Table 2
Ideas, beliefs and images related to the MDP, referred to by candidates that criticized the program.

Ideas	Beliefs and Images
“The program of the Ministry of Health has ‘election’ interests and it is ‘opportunistic.’ “ “The More Doctors Program was evidence of a failure for the Ministry of Health.” “The More Doctors Program is a great myth that is not sustainable in the long term. The Cubans will go back home one day, won’t they? It’s not possible that we have taken 26 years to find out the solution is to import Cuban physicians.”	The More Doctors Program is restricted to emergency provision, and is palliative, transitory and electoral in nature. An insufficient and inadequate program.
"The government failed, since it did not invest in measures such as support for the family health program and increase investments in the sector. They imported physicians because they haven’t graduated. They didn’t support family physicians.”	Pertinence and emphasis of family health. Need for training of professionals, in particular, family physicians.
“The More Doctors Program is 80% propaganda and 20% effectiveness. The same government that makes this propaganda is the government that allowed the exclusion of 13,000 hospital beds in Brazil and left hospitals in misery.” "The More Doctors Program is an excellent program, but it’s like a water tank truck in health care. We have to equip hospitals, give structure to physicians so that they can perform their work."	The program is restricted to emergency provision, and is palliative transitory ion nature. The problem is insufficient investment in hospitals. An insufficient and inadequate program. It highlights hospitals in the system.
"The question regarding the More Doctors Program, the program is important, but it’s not the solution of all programs in Brazil. The participation of the federal government [in health financing] decreased from 54% to 45% during the PT administration. I see health as a broader situation."	Insufficient federal financing in the sector.
"I criticize the More Doctors Program, I never imagined that it was possible to implement a public health policy criminalizing the physicians or turning the population against Brazilian physicians." "Regarding the More Doctors Program, it’s terrible that the PT administration has deliberately turned the population against Brazilian physicians, as if they were responsible for the poor work conditions and especially for the omissions of the federal government on the health financing issue."	This view proposes regulations, is against the program, and criticizes the work and interests of physicians, and intends to criminalize physicians and cause the population to hate them. A priori, the physicians are right, unquestionable. A priori, the state and government are wrong. Maintenance of status and symbolic power of physicians in relation to the society and state.
"We are no longer producing physicians. We are financing a failed government, which is the Cuban government." "We will finance Cuban physicians, not the Cuban government." "We won’t accept the rules imposed by Cuba."	Association of the Brazilian government with the Cuban regime and its policies. Communist danger in Brazil.
"We will pay the Cuban physicians from the More Doctors Program the same amount paid to foreigners." "Ensure that the Brazilian government will guarantee that they receive the same remuneration as other physicians.”	Exploration of the Cuban regime regarding the professionals of their country. Naturalization of the distinction and status of physicians. Need to protect them from the State control.

• Source: Primary data of the study.

Ideas that characterized the MDP as merely a palliative and transitory solution, devised for the election primarily in order to respond to public criticism of failures of government action in the area of health care, were among the most frequent criticisms. The actors emphasize various views. One was the perspective of the centrality of hospitals and equipment, as already discussed, but they also reinforced demands for an increased number of vacancies for medical training in the country, strengthening of primary health care, and increased health financing. The image of a hospital-centered health system, a frequent criticism by those demanding reform of the Brazilian health system, emerges clearly, indicating criticism to the MDP for not adopting the reformist perspective.

Some of the criticism of the program focuses on the government’s relationship with the medical community and disputes of state actors from the federal government with medical representatives. This idea expresses the belief that state interference in regulation of medical training and provision of physicians is criminalization of physicians and incitement to hatred of them by the population. This view involves a strengthened image related to the maintenance of the status and symbolic power of physicians in relation to the society and the state. The participation of Cuban physicians was criticized by raising two central arguments: the inadequate relationship between the Brazilian and Cuban governments; and physician remuneration. The images that these ideas reproduced involved the association of the Brazilian government with the Cuban communist regime, the imposition of social distinctions on physicians, and the need to protect them from state control. The views of candidates about the presence of Cuban physicians changed over time. In July 2014, the views against the presence of Cuban physicians in the country were more frequent and emphatic, such as: Brazil needs more physicians, but it’s not like the PT (the workers’ party) did. We need more physicians, but not through Cuba.

Acceptance of Cuban professionals, defense of their presence, and formulation of alternative proposals for their retention in Brazil began to be defended throughout the period:

In the first place, I won’t allow discrimination against Cuban physicians. Foreign physicians are welcome to Brazil. In our administration, Brazil will create conditions and courses to qualify these physicians so that they can submit to the Revalida (diploma validation test).

The initial views reflected the belief in the inadequacies of foreign physicians, especially Cubans. This image depicted disqualification of these physicians because: they were black; their appearance seemed to be related to lower classes; they came from a communist regime; they supposedly received to low wages; and exploitation by Cuba, which would be accepted by the Brazilian government and indicate the profile the government proposed for a new Brazilian medical category. The changed views of the candidates were related to the public opinion about the program: The evaluation of internal surveys is that the More Doctors (program) is a “marketing tool” that has been highly used by the PT. Since the program receives positive evaluations, the decision was made to defend its maintenance, with some conditions.

The need to maintain a commitment to the interests and beliefs shared by the medical community is seen by the condition that retention of foreign physicians requires that they pass the Revalida, the federal test for the validation of medical diplomas recognized by medical entities. Besides the compulsory Revalida test, proposals to establish a national medical career and other proposals submitted by critics of the program reinforce the ideas defended by the medical community: I will implement policies demanded by health professionals, such as the institution of a national medical career.

The belief underlying the idea of a national medical career, as proposed by the medical community, is that the problem of lack of physicians is related to insufficiency of careers, stability and appropriate remuneration for these professionals. This was defined in the Constitutional Amendment Project 454 of 2009²⁴, which was sponsored by Congressman Ronaldo Caiado; it was defended by medical entities and criticized by the National Health Council (CNS), National Council of Health Secretaries (CONASS), and National Council of Municipal Health Secretaries (CONASEMS). This belief is based on the idea that medical careers are analogous to judiciary careers, but of a national and non-regional nature, that it would be sufficient to ensure the provision and retention of health professionals in places with shortages of medical professionals. However, this belief is not confirmed by research that has been conducted by the World Health Organization to study and systematize strategies developed in the various countries with these programs^25-28. However, the critical views of candidates to the MDP seeking to accept the program as an immediate and “palliative” measure, while they reinforced this belief, avoided conflict with this proposed medical category.

Table 3 shows the ideas of candidates who were favorable to the program.

Table 3
Ideas, beliefs and images related to the MDP, referred to by candidates that supported the program.

Ideas	Beliefs and Images
"The More Doctors Program took physicians to indigenous communities that had no contact with health professionals."	Role of public policy to eliminate inequity and ensure the access to vulnerable populations. Developing solidarity and eliminating inequality.
"The program is important to ensure the provision of care in locations that lack health care, since there are no professionals interested in working in these areas. The program is in the interior and capitals where there are no physicians." "It’s a mistake to think that the program covers remote regions, since it covers cities of high populations who are unassisted."	Role of public policy to eliminate inequity and ensure access to vulnerable populations. The lack of access and care is not restricted to rural and remote areas of the country; it is also in peripheral regions of urban centers. Developing solidarity and eliminating inequality.
"It meant more than 14,000 professionals, ensuring 50 million services in a record period to expand the provision of care.”	Efficiency of public policies and intervention of the State. The State is able to perform huge actions in proper deadlines.
"Besides increasing the provision of services in primary health care, the program helps relieve emergency services, because there are many physicians in primary healthcare." "The More Doctors Program provides care near home.”	Proximity and resolution in primary health care, and impact on other services. Expanding access to primary health care.
"Expand the number of specialists brought in by the More Doctors Program, to meet the demands of the population, who wait for months for specialized care." "More specialist physicians will prevent people from travelling to other cities to receive care."	Demand for more physicians and considering the possibility of a similar alternative to expand access to specialists. Success of the program to be expanded to specialties
"The More Doctors Program was adopted in a hurry, to respond to the protests that occurred in June 2013." "We didn’t create the More Doctors Program because of the protests in July. The program was already being developed." "The More Doctors Program was created to fulfill a demand by mayors from all over the country and by all parties."	State actors, regardless of their political party, have more influence in demanding public polices than popular protests. Responding to popular protest is an electoral attitude. Hierarchy among the actors in demands for public policies.

• Source: Primary data of the study.

The ideas presented by the candidates who were favorable to the MDP can be classified into four categories: 1) pertinence – of emergency provision, the presence of foreign professionals, and expanded access to health for vulnerable and unserved populations; 2) importance – for the qualification of primary health care and its role in the response to health needs; 3) extrapolation – extension of the More Doctors Program to specialized care; and 4) demand – justification for the creation of the program as an institutional demand by state actors (mayors), regardless of their political party.

The ideas presented so far, whether favorable or critical to the MDP, reinforced the belief that the program is restricted to emergency provision. They reproduced the image that the participation of foreign professionals, especially Cubans, was the main issue in dispute. The theme of changes in medical training, as addressed in the law³, took second place in the views of the candidates presented by the media. When referenced, it was restricted to proposals to increase the number of vacancies in medical training and residency:

Cuban physicians who wish to remain shall have their salaries paid in full and shall receive political asylum. Then, we will have time to invest in increasing the number of places for medical students in public and private universities.

We will make a public policy with the physicians, with all health professionals, training Brazilians in the interior of Brazil to take care of Brazilians; expanding training public universities, not only in undergraduate courses, but also in the specialties that Brazil needs.

The program also foresees an additional 11,000 places in medical courses and 12,000 in medical residencies to meet future demand. Sometimes an opportune solution, when the population needs it, does not provide a structure, but it was not possible to wait for new medical courses while the population fell ill and died. The MDP is more than the 14,000 physicians allocated to the most vulnerable municipalities.

It can be seen that both candidates who were for the MDP and those against the program propose an increase in the number of medical jobs, reinforcing the previously presented convergence regarding the belief that it is necessary to increase the number of physicians in the country, by expanding undergraduate courses and residencies. However, the content and directionality of changes in training, even according to the law, was not discussed. The role of the state in regulating the provision of medical training, providing jobs, reformulating proficiency profiles of professions, and offering regionalization, was not addressed by the candidates.

Discussion and conclusions

The analyzed data showed that the theme of medical provision in the SUS and, more specifically, the implementation of the MDP for emergency provision was incorporated into a broader political debate. It went beyond the subsystem or field of health and was assumed to be an agenda of strategic actors involved in the political system and, therefore, in the dispute of meanings and identities of the social actors during the election period. But this did not happen to a significant extent with program proposals for infrastructure qualification and changes in medical training, not even regarding the notion of healthcare coverage by multi-professional teams, healthcare territorialization and healthcare network logic.

Regarding emergency provision, the MDP became an issue that the candidates referred to in competition for public recognition during the election process. It should be noted that, in this case, both favorable and unfavorable candidates said publicly that the program was a necessity and that they would be committed to it. Views that opposed the program or questioned the need for it were rare.

This is understandable, considering the need for skillful strategic actors to publicly assume positions, by responding to or building on the preferences of people and the environment. That is, in the electoral process, the ability of strategic actors to read and win the attention of voters is in question, since they position themselves as representatives of these expectations, of the meanings and identities shared among the social actors. The fact that most candidates expressed favorable views is partially explained as a result of a number of surveys and evaluations of public opinion that showed that the population approved of the emergency provision of the MDP.

The process of public debate about whether the program was pertinent favored candidates who implemented it and candidates who wanted to have support from and share identity with voters who favored its maintenance. This implies that proposals about changes in policy direction, such as the end of the program, could lead to loss of support for the actors who made them. It is noteworthy that fewer views by the candidates were published on the media regarding the MDP in October 2014, which was the last and decisive period in the election process, the run-off election. Analysis of the databased for this period showed that, most health reports were about the Ebola outbreak in Africa.

In the development of public policies, problem definition is relevant because it is an indication for solution design¹⁴. The convergence of candidate views that the problem is the shortage of physicians and the solution is to provide more physicians indicates that it is a shared meaning, with which most Brazilians identify, since the intention of these actors is to represent the preferences of their voters. The view differs from that of the medical community, which maintains that there are sufficient physicians in Brazil^2,4.

It should be noted that problem definition is a central issue in the formulation of public policies. If the problem was identified a shortage of professionals to ensure health care, proposed solution could include: expanding the scope of practice of other professionals; revising the regulation of private acts of the various professions; and revising the work processes of health teams. These ideas about problems and their solutions have been, and still are, on the agendas of health actors, such as disputes about the Medical Act legislation, but they did not appear in the agendas of the candidates. Ideas that defend the priority of hospital investments, such as health system problems and solutions, were infrequent when compared to those that supported the priority of primary health care and the expansion of specialists in the health system as a whole, as a response to healthcare qualification. These ideas expressed different beliefs and images about health system organization and the technical and care models that should guide it. On one side was the perspective of centrality of hospitals and hard technologies, and on the other, the perspective of integrality, with access to professionals being based on actions, contact, encounters²⁹.

For public policy changes or consolidation, it is important that the actors share senses and meanings and identify themselves with the problem diagnosis and proposed solutions. The demand for more professionals, the expansion of the scope of multi-professional team practice, and the need to invest in the infrastructure of services, hospitals and primary care units in order to expand and qualify care are not necessarily problems and solutions for exclusion. However, divergences and convergences regarding the relevance of proposals and shared beliefs and images directly influence the priorities of state actions and, therefore, the scope of public policies.

In order to achieve significant changes in public policies, the themes should be included in the agendas of the actors, and the ideas, beliefs and images related to the need and directionality of the changes need to be shared. The fact that the proposals for reformulating medical education are not highlighted in the media, in the agendas of candidates and, consequently, those of the general public indicates that: 1) These changes are less relevant for the actors in state policy in general; 2) These are ideas not widely known to most actors and with which they do not identify; 3) They imply proposals about which there is conflict and low ability to bring actors together in the society; 4) They are recognized as issues addressed to specialists; and 5) They will remain restricted to the field of health and education, once they are already foreseen by law, in a context of considerable dispute between the actors in the implementation process.

Particular attention should be paid to the belief about the differentiated status of physicians related to specialized training. The image of technical, political and financial superiority attributed to specialists in relation to general physicians, general practitioners, and family and community physicians, shared by the collective actors and by current and new medical graduates, will be relevant in the consolidation process for new rules for medical residency foreseen in the program rules³. In election processes, once changes in or continuity of political coalitions in the state administration come into question, there is evidence of disputes about consolidation of, and incremental or radical changes in, existing public policies. In the processes of public policy implementation, the media are recognized as a symbolic dispute locus among the actors. Therefore, predominantly favorable views support and facilitate the implementation process of public policies that are in progress, while predominantly negative views may even jeopardize this implementation³⁰.

In the case of the MDP, specifically the aspect of emergency provision and an increase in the number of vacancies in training and medical residencies, views that favored consolidation or incremental changes were more frequent, suggesting a significant political cost for radical changes. In any case, it is important to consider that the theme of the provision of health professionals, in particular physicians, and the visibility that the organization of primary health care services of the SUS had in the election process agenda, showed important relevance among the governmental policies and priorities. Continued analyses are needed to monitor variations in this situation and the production of new discursive constructions of the various actors, indicating the rise or decline of this theme in public policy agendas.

Referências

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Publication Dates

• Publication in this collection
  2017

History

• Received
  20 June 2016
• Accepted
  23 June 2017