The resumption of the Mais Médicos Program in 2023

Abstract

Healthcare gaps and the demand for physicians in the Brazilian Health System are chronic problems, especially in the most vulnerable regions of the North and Northeast and in peripheral areas of urban centers. In view of this need, the federal government is recomposing the Mais Médicos Program for Brazil, through the ministries of Health, Education and Finance. The main axes of the program are the provision of doctors in Primary Health Care and the training of these professionals, in this version associated with specialization and professional master’s, with reference to the concept of primary care for integral health. In this note of conjuncture, we bring information about the official trajectory of this recovery movement, briefly recovering characteristics and advances provided by this policy – first established in 2013 – and presenting peculiarities of the current version, proposed by provisional measure n. 1.165, of March 20th, 2023, converted into law (n. 14.621/2023) and sanctioned in July of this year.

human resources in health; medical education; health training; public policy; Mais Médicos Program

Resumo

Os vazios assistenciais e a demanda por médicos no Sistema Único de Saúde são problemas crônicos, principalmente nas regiões mais vulneráveis do Norte e Nordeste e em áreas periféricas de centros urbanos. Frente a essa necessidade, o governo federal está recompondo o Programa Mais Médicos para o Brasil, por meio dos ministérios da Saúde, da Educação e da Fazenda. Os principais eixos do programa são a provisão de médicos na Atenção Primária em Saúde e a formação desses profissionais, nessa versão associados à especialização e mestrado profissional, tendo como referência a concepção de Atenção Primária à Saúde integral. Nesta nota de conjuntura, trazemos informações sobre a trajetória oficial deste movimento de retomada, recuperando brevemente características e avanços proporcionados por essa política – instituída primeiramente em 2013 – e apresentando peculiaridades da versão atual, proposta pewla medida provisória n. 1.165, de 20 de março de 2023, convertida em lei (n. 14.621/2023) e sancionada em julho deste ano.

recursos humanos em saúde; educação médica; formação em saúde; política pública; Programa Mais Médicos

Resumen

Las brechas de asistencia y la demanda de médicos en el Sistema Único de Salud son problemas crónicos, especialmente en las regiones más vulnerables del Norte y del Noreste y en las zonas periféricas de los centros urbanos. Ante esta necesidad, el gobierno federal está recomponiendo el Programa Mais Médicos para Brasil, a través de los ministerios de Salud, Educación y Hacienda. Los principales ejes del programa son la provisión de médicos en Atención Primaria de Salud y la formación de estos profesionales, en esta versión asociada a la especialización y maestría profesional, con referencia al concepto de atención primaria para la salud integral. En esta nota de coyuntura, traemos información sobre la trayectoria oficial de este movimiento de reanudación, recuperando brevemente las características y los avances proporcionados por esta política – establecida por primera vez en 2013 – y presentando las peculiaridades de la versión actual, propuesta por la medida provisional n. 1.165, del 20 de marzo de 2023, convertida en ley (n. 14.621/2023) y sancionado en julio de este año.

recursos humanos en salud; educación médica; educación en salud; política pública; Programa Mais Médicos

Gaps in healthcare coverage and the demand for physicians within the Brazilian National Health System (Sistema Único de Saúde, SUS) are chronic issues, especially in the more vulnerable regions of the North and Northeast, as well as in the outskirts of urban centers in Brazil. In response to this demand, in 2013, the federal government, along with the ministries of Health, Education, and Planning, embarked on a bold initiative to tackle this problem.

The Provisional Measure (PM) No. 621, issued in July 2013 by the Presidency of the Republic, introduced for the first time the Mais Médicos (More Doctors) Program (PMM). This measure encountered strong resistance, including from the Federal Council of Medicine, during its processing and approval in the National Congress. After several rounds of negotiation, the PMM was established by Law No. 12.871, enacted in October 2013 (Brasil, 2013), with the aim of serving the Brazilian population through basic healthcare services within SUS, utilizing various educational, research, and extension approaches.

Mentoring and supervision of the physicians participating in the program were under the responsibility of the Ministry of Education, following a framework based on the principles and pedagogical guidelines of ongoing education in health. Each mentor manages ten supervisors, who are qualified physicians for the role, and each supervisor directly manages ten physicians.

The main aspects covered by the PMM were: strengthening service provision; reorganizing the offering of medical courses and residency positions, prioritizing health regions with lower ratios of positions and physicians per inhabitant, and with healthcare infrastructure capable of providing sufficient and quality practical training opportunities for students; establishing new standards for medical education in the country; and promoting the enhancement of physicians’ skills in primary health care in priority regions of the SUS by integrating education and service, including international exchange (Brasil, 2013).

The positions were initially offered, preferably, to physicians registered with the Regional Medical Councils. If not filled, they were allocated to professionals with foreign medical degrees who obtained registration from the Ministry of Health. It’s important to note that thousands of these positions were filled by physicians from Cuba, who have developed an important and competent work for the Brazilian population.

The PMM consistently faced strong opposition from organized groups that Pinto and Cortes (2022) referred as the Political Community for the Defense of Liberal Medicine. This group included medical professionals who were also congressmen, leaders of medical associations, hospitals, medical schools, and residency programs (Pinto and Cortes, 2022; Costa, Carvalho, and Macedo, 2023). Studies aimed at understanding what made the implementation of the PMM possible in 2013, point to worsening problems related to the insufficient and uneven distribution of physicians. This led the National Front of Mayors to launch the “Where’s the Doctor?” campaign that year. The issue gained presence in the media, influencing public opinion, and President Dilma Rousseff, in her inaugural speech, committed to the training and presence of healthcare professionals in different regions of the country, establishing a priority that is now being revisited. In this context, the strong efforts of leaders and experts, especially within the Ministry of Health, were noteworthy. They recognized the crucial connection between these two components, education and healthcare provision, in addressing the core issue of improving the quality of the SUS (Ribas, Silva, and Dias, 2019; Pinto, 2021; Pinto and Cortes, 2022).

In the aftermath of President Dilma’s impeachment and amidst constraints on social policy financing, the Temer administration scaled back the efforts within the education and infrastructure axis, essentially maintaining only the provisions aspect of the program (Costa, Carvalho, and Macedo, 2023).

In 2019, during the Bolsonaro administration, the PMM was replaced by the “Programa Médicos pelo Brasil” (Doctors for Brazil Program – PMpB), as per Law No. 13.958 enacted on December 19, 2019 (Brasil, 2019). This law also authorized the Federal Executive Branch to establish an autonomous social service entity named “Agência para o Desenvolvimento da Atenção Primária à Saúde” (Agency for the Development of Primary Health Care – Adaps).

It is within this context that the PMM, established in 2013, began to coexist with the PMpB. During this phase, federal administrators managed both programs simultaneously, with the implementation of the new program bringing about challenges in terms of filling vacancies that were not occupied by the PMpB.

The Bolsonaro administration’s opposition to the PMM and the resulting competition between the programs, as noted by Costa, Carvalho, and Macedo (2023, p. 12), “generated tragic results in rural Amazonia (...) as the PMM was deliberately weakened, the PMpB failed to cross the border of ministerial rhetoric, bypassing assistance gaps”. According to data from the Ministry of Health, a significant decrease in the number of professionals within the PMM was observed. When comparing the months of January 2018 and January 2023, there was an approximate 36% reduction in the number of medical professionals.

In 2023, the Lula administration reinstated the PMM, henceforth called More Doctors for Brazil Program (PMMB), through Provisional Measure (PM) No. 1.165/2023 (Brasil, 2023a). This revival of the program extended its objectives by establishing the National Strategy for Specialist Training in Health Care within the framework of the PMM, and it also brought amendments to Law No. 12.871/2013 (Brasil, 2013). On July 14, 2023, the PM was converted into Law No. 14.621 and was sanctioned by President Lula.

The proposal for Provisional Measure No. 1.165/2023 (Brasil, 2023a) was outlined in the explanatory memorandum signed by the Minister of Health, Nísia Trindade Lima, the Minister of Education, Camilo Santana, and the Minister of Finance, Fernando Haddad. The PM was submitted to the President of the Republic, who attached it to the document forwarded by the Executive to the National Congress. The MP was issued in March 2023 and underwent an expedited legislative process, leading to the suspension of the Congress agenda in May. In the same month, Interministerial Ordinance No. 604/2023 (Brazil, 2023d) was issued, outlining the implementation of the Mais Médicos (More Doctors) program. During May, a joint committee consisting of members from both the Chamber of Deputies and the Senate was formed, with Senator Zenaide Maia (a medical doctor) as the rapporteur. Throughout the legislative process, four public hearings were held for discussion. The committee’s report was approved on May 31, and the MP was sent for voting. On June 14, it was approved in the Chamber of Deputies and subsequently in the Senate on June 20, 2023. On July 14, the Provisional Measure (PM) was converted into Law No. 14.621.

The agility with which the PM was crafted and moved through Congress is indicative of the significance attributed to the subject matter. By April 14th, the announcement for the 28th cycle of the PMMB had already been made public, outlining the eligible municipalities for 6,252 program positions. Notably, this cycle introduced an unprecedented allocation of 1,000 positions for the Legal Amazon region. In May, Public Notice No. 4 and No. 5 were published, inviting medical professionals to participate (Brasil, 2023e; 2023f).

Provisional Measure No. 1.165/2023, in addition to establishing the National Strategy for Specialist Training in Health Care within the framework of the PMM, brought about amendments to several laws, including: Law No. 12.871, enacted in October 2013. Law No. 13.959, enacted in December 2019, which introduced the Revalida (Medical Residency Exam) program and Law No. 13.958, enacted in December 2019, which established the PMpB.

The text of PM No. 1.165/2023, prepared by the Lula Government, did not address diploma revalidation. The National Congress, based on the public hearings, made proposals to include the topic in the MP through amendments. A similar situation occurred with the Adaps, which received an additional proposal from the rapporteur of the joint committee, transforming it into the Brazilian Agency for Support to SUS (AgSUS). The text of the PM, after accommodating these additions, led to the creation of the conversion law bill No. 13 (Brasil, 2023b).

The interministerial explanatory memorandum (Brasil, 2023c) provides a detailed overview of the new proposals established within this strategy, which is worth revisiting. The ministers emphasized that federal programs for the provision of physicians to Primary Health Care (APS) currently have the lowest number of active physicians since 2014, significantly impacting healthcare services to the population, especially the most vulnerable. Additionally, approximately two thousand physicians are expected to leave the program in the coming months (upon the end of the three-year term for scholars’ attachment to the PMpB). This has made it even more urgent to adopt measures to ensure the population’s access to qualified healthcare professionals.

In light of this context, the three ministers noted that the proposal of Provisional Measure (PM) No. 1.165/2023 (Brasil, 2023a) was developed with the aim of: addressing the shortage of Primary Health Care physicians in priority regions for the SUS, in order to reduce health inequalities; strengthening service provision in Primary Health Care; broadening the scope of Primary Health Care practices through improved training and the education of medical specialists for the SUS; to ensure comprehensive and integrated care throughout the life cycles by integrating education and health; expanding the availability of professional specialization in strategic areas for the SUS. The interministerial explanatory memorandum (Brasil, 2023c) further highlights that Primary Health Care is recognized for promoting better and more equitable health outcomes.

Scientific evidence demonstrates that countries with healthcare systems that heavily invest in Primary Health Care tend to exhibit better health conditions among their populations, greater equity, lower rates of unnecessary hospitalizations, and, consequently, a lower rate of healthcare expenditure growth (Kringos et al., 2015). A study that investigated the impact of the PMM revealed a reduction in hospitalizations among children and adolescents under 20 years old in rural municipalities (Özeçelik, 2023).

In a didact manner, the ministers assert that Primary Health Care not only has independent effects on health but also enhances the effectiveness of other social programs. Some research shows, for example, the combined impact of Family Health teams and the Bolsa Família Program in providing greater protection for children covered by both strategies (Rasella et al., 2013; Silva and Paes, 2019). The ministers state that despite efforts made since its inception in 1998, Primary Health Care actions do not cover the entire Brazilian population. The Ministry of Health estimates the current coverage to be around 69% of the population. The National Health Plan 2020-2023, published in February 2020, aims to expand the population coverage target of Primary Health Care to 72.71% by 2023. It’s worth noting that this target refers to Primary Health Care coverage and may not explicitly include the coverage of the Family Health Strategy, a model that includes a full healthcare team and community health workers. While this discussion goes beyond the scope of the present text, it holds significant importance for the SUS.

The explanatory memorandum also provides information about recent initiatives aimed at addressing the challenge of providing and retaining Primary Health Care professionals in vulnerable regions, such as rural areas and outskirts of major cities. The most significant of these initiatives was the PMM, launched in 2013 (Brasil, 2013). The PMM had a substantial impact, with 18,240 medical professionals working in 4,058 municipalities and 34 Special Indigenous Health Districts across all regions of Brazil. This allowed for the coverage of 63 million Brazilians.

In 2015, the PMM had covered all Special Indigenous Health Districts in the country, ensuring that each one had access to medical professionals for the first time (Pinto, Oliveira, and Soares, 2022). Costa, Carvalho, and Macedo report that “the state of Amazonas, for example, had 435 physicians working for the PMM in 2016, of which 351 were Cuban exchange doctors” (2023, p. 6). It’s worth noting that several measures were implemented to support the program in remote rural municipalities, particularly in the Amazon region, leading to positive outcomes (Costa, Carvalho, and Macedo, 2023).

The PMM succeeded in implementing various strategies to provide and retain physicians. Examples of these initiatives were in the field of education, including the expansion of undergraduate medical school positions and changes in criteria for opening new programs. These changes aimed to bring new medical courses to underserved regions with gaps in healthcare access.

Despite the positive outcomes achieved by the PMM, this public policy began to be reduced starting in 2017, a process that was intensified from 2019. As a result, the PMpB currently reported 8,613 active professionals. Presently, it is estimated that around 14.7 million Brazilians are no longer covered by federal programs for the provision of physicians, a situation worsened in more vulnerable areas. Indigenous health, which was previously 100% covered by the PMM, but in 2023 it had only 58% coverage.

According to Nésio Fernandes, the Secretary of Primary Health Care at the Ministry of Health, the average tenure of medical professionals within the same Family Health team over the last ten years has been only six months, or even less in some more vulnerable areas. This short duration directly impairs the quality of work in Primary Health Care. However, when focusing on professionals within the scope of the PMM this average is significantly higher, reaching twenty months, demonstrating a greater capacity for retention of these professionals when linked to the program (Fernandes, 2023).

The three ministers emphasized that the described scenario necessitates urgent measures to strengthen federal efforts for the provision of physicians. At the same time, improvements are proposed for the PMMB to enhance its educational aspects, particularly by increasing the number of specialists in Family and Community Medicine.

It is from these two concerns – the provision/retention of physicians and advancements in the training process – that the most significant innovations of the PMMB 2023 arise.

One of the proposed strategies concerns the strengthening of the Family and Community Medicine Residency through the establishment of compensation for physicians benefiting from the Student Financing Fund (FIES) who complete the two-year program. Provisional Measure No. 1.165/2023 (Brasil, 2023a) also aims to extend the period of stay for PMMB professionals in Primary Health Care. It introduces a training framework involving a two-year specialized training (lato sensu) and an additional two-year professional master’s degree, completing a four-year training cycle (double the time of the Family and Community Medicine residency). At the end of these four years, in accordance with the rule established by the Brazilian Medical Association in agreement with the Federal Medical Council and applicable to other specialties, the professional can undergo an examination for the title from the Brazilian Society of Family and Community Medicine (SBMFC). In the PMMB 2023, within four years, three titles can be earned: lato sensu specialist, professional master’s degree, and specialist title from the SBMFC. Thus, the PMMB solidifies itself as a strategy for training specialists, with the responsibility of monitoring the quality of this training.

Furthermore, is proposed a financial bonus for working in areas of difficult retention for professionals, which can be paid in two modes: an amount equivalent to 20% of the total scholarships received by the doctor over a 48-month period if they work in a vulnerable area indicated by the Ministry of Health and an amount of 10% of the total scholarships if they work in other challenging areas. For professionals who were FIES beneficiaries, this compensation reaches 80% of the amount received by the participating doctor over a 48-month period if they work in a vulnerability-indicated area by the Ministry of Health, or 40% of the total scholarships if they work in other challenging areas. This measure aims to enhance the retention of professionals in the most vulnerable areas, considering that physicians who benefited from FIES have up to 30% higher chances of working in smaller municipalities with a low Human Development Index (Figueiredo et al., 2023).

Regarding the professionals who can apply for the new PMMB program, the prerequisite is the recognition of professional practice (medical license) in the country of education. There are three defined profiles: registration in Brazil, Brazilian with registration/professional practice in another country, foreigner with registration/professional practice in another country (Brasil, 2023g).

As for the evaluation process, the interministerial ordinance Ministry of Health/Ministry of Education No. 604, issued in May 2023 (Brasil, 2023d), which governs the program’s execution, stipulates that participating physicians will undergo an annual performance assessment with an elimination criterion. Their performance in carrying out activities and their continuation in the project will be evaluated. The assessment is conducted by the supervisor and the municipality or Federal District.

The remuneration is a form of a scholarship for training, through which the medical professional commits to a weekly workload of 44 hours, consisting of 36 hours of healthcare activities and eight hours of distance learning training. It should be noted that a scholarship does not establish an employment relationship and therefore does not guarantee labor rights. However, a paid leave of thirty days is provided for every year of work.

According to information from the Ministry of Health, in the current phase, 34,000 professionals have responded to the Public Notice No. 4, issued in May (Brasil, 2023e), of which 27,400 have indicated a location for their practice. Regarding the profiles, 84.7% correspond to profile 1 (priority), e.g., native Brazilians and graduated physicians in the country, while 15.3% are physicians of profile 2, Brazilian physicians with professional registration and practice abroad (Brasil, 2023d). Since April 2023, when Public Notice No. 4 was launched (Brasil, 2023e), the first under the new government administration, 14 public announcements have been issued up to August 2023.

Minister Nísia Trindade and ministers Camilo Santana and Fernando Haddad state that the budgetary and financial impact for the current year is R$ 712.5 million, which will be fully covered by the allocations set out in the Annual Budget Law for 2023. For the following two years, the estimated expenses are around R$ 3 billion and will be provided for in future annual budget laws. In this new conception, the Ministry of Health has also formulated a co-participation model, in which the requesting municipality (voluntary participation) covers the amount corresponding to the monthly base of the scholarships paid to professionals linked to the program in this category, deducted from the financial transfers from the fund-to-fund allocation. These positions are offered in specific public announcements and represent a new avenue for program expansion.

The first public notice of this type, in June 2023, had so many municipalities applications that the demand exceeded the number of vacancies planned.

Before concluding this note, it is worth highlighting some tensions that are already part of the health work and education scenario, with which the program interacts directly, and which has been demanding complementary strategies. Firstly, it is important that the PMMB joins the effort to consolidate the ESF and, in this regard, it is important to prioritize the allocation of doctors to family health teams, rather than primary care teams. It is known how difficult it is to resolve this tension, particularly within the National Council of Municipal Health Secretariats (CONASEMS). It is necessary to pay attention to the time allocated to training, so that the characteristic pressure of services in areas suffering from a shortage of medical work does not jeopardize training, which is fundamental for the qualification of these professionals. Finally, we should not minimize the fact that hiring on a scholarship is part of the work precarization and that, therefore, more stable forms of employment with guaranteed rights should be promoted.

Converted into a comprehensive strategy, the expansion of the program is justified by the qualification of care and increased access to PHC services, with broad positive effects on health conditions and comprehensive care for SUS users. As for the urgency, this stems from the potential increase in the population’s lack of health care if immediate measures are not taken to attract and retain new doctors for Primary Health Care. However, its value as a state government policy also stems from its ability to formulate approaches to historical problems that project social benefits in the medium and long term for the Brazilian population.

Referências

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• Ethical aspects
  Not applicable.
• Preliminary presentation
  Not applicable.

Publication Dates

• Publication in this collection
  06 Oct 2023
• Date of issue
  2023

History

• Received
  20 June 2023
• Accepted
  20 July 2023