Challenges for ensuring availability and accessibility to health care services under Brazil’s Unified Health System (SUS)

Oliveira, Ana Paula Cavalcante de; Gabriel, Mariana; Poz, Mario Roberto Dal; Dussault, Gilles

doi:10.1590/1413-81232017224.31382016

Ana Paula Cavalcante de Oliveira

Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa. R. da Junqueira 100. 1349-008 Lisboa Portugal. paula.cavalcante@ihmt.unl.pt

Mariana Gabriel

Departamento de Odontologia Social, Faculdade de Odontologia, Universidade de São Paulo. São Paulo SP Brasil.

Mario Roberto Dal Poz

Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro. Rio de Janeiro RJ Brasil.

Gilles Dussault

Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa. R. da Junqueira 100. 1349-008 Lisboa Portugal. paula.cavalcante@ihmt.unl.pt

Collaborations

APC Oliveira worked on the conception of the study and methodology, collection and analysis of the data, structuring and writing of the article and revision of the drafting in all the versions including the final one; M Gabriel worked on collection and analysis of the data, structuring and writing the article in all the versions and revision of the final draft; and MR Dal Poz and G Dussault worked on the design of the study and revision of the drafting of the article in all the versions including the final one.

Location of search	Specifications of search	Criteria for inclusion and exclusion of documents
PubMed and BVS	Systematic search, in January 2016, in the databases of the Virtual Health Library (BVS), and PubMed of the National Library of Medicine, where the scientific documents were identified based on a search using the following terms: (physician OR physicians OR doctor OR doctors OR health professionals OR workforce OR health workers OR manpower) AND (geographical OR imbalance OR rural OR remote OR suburban OR scarcity OR lack) AND Brazil - details of the search are available on request. Finally, documents identified as relevant (related to the structure of the problem under study or to a specific strategy) as a result of the initial references selected, were included.	(i) The material should be about medical professionals, whether or not including other professionals;
		(ii) when about more than one country, it should enable information relating to Brazil to be identified in isolation;
		(iii) it must be available in computerized form, making possible searches for information in the text;
		(iv) dated 1994-2015;
		(v) and without language restrictions;
		(vi) principal subjects to include geographical availability or accessibility of healthcare human resources as principal focus of the article in one of three aspects: geographical availability/distribution of doctors; causes of scarcity or asymmetric distribution; or strategies for dealing with the problem: whether (a) describing or assessing the strategy in its implementation in Brazil, or (b) describing or assessing a strategy implemented in another country, raising considerations for its implementation in Brazil.
Websites	Research on websites of the Brazilian Health Ministry (HM), International organizations (World Bank, OECD, WHO, Inter-Agency Health Information Network (Rede Interagencial de Informação para a Saúde, RIPSA), and Health Graduations Indicator Systems (Sistemas de Indicadores das Graduações em Saúde, SIGRAS), the Brazilian Federal Council on Medicine, and the Brazil Health Human Resources Observation Network (Rede Observatório de Recursos Humanos em Saúde do Brasil, ObservaRH), with a focus on the work situations that have lines of study or research on the subject in question.	Documents that presented data without the results of processing it or without introduction of new conclusions were excluded.
Individual key advice and information sources	In parallel, key information sources were consulted to identify possible documents not included in the previous phases (items published, and the ‘gray literature’), or names of strategies that would enable a specific search on the sites described.	The year 1994 was chosen as a cutoff due to the implementation of the Family Health Strategy (ESF).This choice is justified by the fact of healthcare being organized based on the precept of Primary Health Care (PHC).

Question	Category	Subcategory
What are the challenges identified by policy makers and managers in ensuring geographical availability and accessibility to doctors within the SUS system?	Stock of qualified healthcare human resources and their characteristics in terms of distribution	Scarcity of professionals; distribution between rural and urban; distribution of professionals between public and private; among other aspects.
What are the determinant factors in these challenges?	Education sector and dynamics of the market	Number of graduate positions available, number of specialization positions, planning in the form in the training of healthcare professionals, number of retirements, loss to the private sector, unemployment, emigration, double employment, inefficacious contracting procedures; among other aspects.
What strategies and areas of policy interventions were used to correct the challenges faced by policy makers and managers at the national level to ensure geographical availability and accessibility for doctors within the SUS system?	Areas of political strategies	Policies surrounding training of healthcare professionals, policies surrounding flows of entry and exit, among other aspects.

Political Intervention	Aim/Description	Important Points
Rondon Project: 1968 - 1989, and 2005 - present	This program aimed to promote service internships for university students⁴⁸ and consequently bring students to the work in areas of difficult access and health services that were expanding³⁶. In 2005 it was re-launched and now has representatives from the Defense, Education, Health and other Ministries⁴⁹.	In its 22 years this project has served thousands of municipalities, most of them in the Center-West, Northeast and Northern Regions of Brazil³⁶.Some 350,000 university students and 13,000 teachers have taken part in the project^35,36. The literature that was analyzed does not indicate the reasons why it was terminated. Since the re-launch of the project, it has involved 1,900 higher education institutions and carried out 69 operations in 854 municipalities in 23 States⁵⁰.This intervention focused on the area of policies directed to training and qualification, and did not coordinate with other areas of political interventions. Although the literature indicates that for a student to live in a less accessible environment widens his choice for future work17, no data was found for any monitoring of these students after graduation.
PISUS: 1993 - 1994	The objective was to take into the interior of each region or state a minimum health team comprising a Community Health Agent, Nurse and Doctor to support one health service35.It was organized in four sub-programs: (i) first aid units, (ii) establishment of a doctor in a region of the interior (at least one to establish fixed residence in the participating municipality), (iii) interiorization of the nurse, and (iv) the Community Agents³⁶. It offered appropriate physical facilities, accommodation for nurses and doctors, payment for production, and a formal contract executed by the municipal manager using funds passed through from the Health Ministry^35.	This program reached ٣٩٨ municipalities^٣٥. Since it lasted only for a short time, the lack of information about the reasons why it was terminated prevents any future action in this area from correcting possible fragilities. This is a factor that inhibits continuity of political initiatives.
PITS: 2001 - 2004	This aimed to encourage placement of qualified health professionals in municipalities with proven shortage of medical and health resources⁵¹, distant from state capital cities, and also help expand basic healthcare and the Family Health Program (PSF)³⁶. Coordinated at a national level by the Health Ministry, it adopted the same strategy as the PSF, and made use of financial incentives, continuing education for participating professionals, and professional and personal support through appropriate work conditions (equipment and inputs), and accommodation, food and transport for them to carry out their activities³⁶.The participating doctors did the specialization course in Family Health⁵².	During the period, the program was applied for ٤٢١ health professionals, ١٨١ of them doctors, in ٣٠٠ municipalities^٣٥. It can be seen that this program had greater articulation of the strategies to motivate the health professional, but as with the previous program (PISUS), above, it was also not possible to find out the reasons for its termination.
Telessaúde: 2007 - present	This was a strategy that was a part of the National Permanent Health Education Policy implemented as one of the actions of the Mais Saúde (More Health) program^55,56. Its objective is to orient qualification and development of health human resources and improvement of care and management in basic healthcare in the SUS^55,57. It integrates teaching and service, also providing distance healthcare and distance education, through ICT⁵⁵.	This strategy has been related to the attempt to improve the number of health professionals who establish permanent residence in remote areas, since it helps to reduce the possible sensation of isolation and clinicalin security^٥٥,٥٧. Studies point to the contributions of ‹tele-health› in the sector^٥٨,٥٩, demonstrating that technology can be a strong ally in exchange of knowledge and training of professionals of the network. This is an area that is expanding, and likely to be explored in the future in the policies relating to health human resources.
Pró-Residência: 2009 - present	An inter-sector measure between the Health Education Ministries. It aims, through award of grants, and training of specialists in basic and priority areas for some regions of the country (North, Northeast and Center-West), to provide support and opening of new residency programs based on the need of the region⁶⁰.	Since local and regional shortages in specialists in certain areas of medicine are diagnosed and reported, this initiative has the potential to help in the choice of the professional’s activity, thus helping both the market and the doctor’s career.
FIES: 2011 - present	In 2011 the government made it possible for doctors whose graduation had been financed by the FIES to pay off their debts by working in the teams of the Family Health Strategy (ESF) in areas where there was a shortage of doctors. For each month worked, the deduction was 1% of the debtor balance⁶¹.	It has contributed to expanding the number of doctors in the country, enabled various students to conclude their course through this financing. Linking the student debt to the professional working in the SUS is one more way of expanding the store of doctors in the service and contributing to a reduction of the disparities in health.
PROVAB: 2011 - present	This aims to provide Basic Healthcare and Family Health Strategy teams with nurses, dentists and doctors, in areas that are remote and more vulnerable (riverbank populations, Quilombo settlements, new country settlements, indigenous people, etc.), thus achieving integration between teaching, service and community. The professionals receive a study grant paid by the Federal Government, distance and in-person supervision, and the opportunity to carry out a specialization course focused on basic healthcare offered by universities participating in the UNA-SUS⁶⁰.At the end of the year, the doctors can receive up to 10% of the total 100% marking the points system of the process of selection for medical residency³⁵.	The number of participants increased from 381 in 2012 to over 3,300 in 2013, distributed between 1, 157 municipalities, of which 573 are located in the Northeastern Region⁶². In 2015 the PROVAB was integrated into the PMM (‘Mais Medicos’) Program.
‘More Doctors’ Program (PMM): 2013 - present	This program aims to train doctors and take them to regions where health professionals are scarce or absent⁶⁵. It is structured in three parts:(1) improvement of basic healthcare structure - improvement in infrastructure of the RAS, focused on Basic Health Units (UBSs); (2) medical training, changes in graduation - in medical residency and training of specialists, such as, for example, implementation of the new DCN and expansion of graduation courses in the public and private sectors; and (3) the emergency provision aspect - the program provides doctors on an emergency basis in vulnerable areas (by recruitment of Brazilian and foreign doctors either individually or through a bilateral agreement made with the government of Cuba)³⁷. The participant receives a monthly grant and cost support for the facility³⁷, of which the amounts are higher for those that travel further to more remote areas⁷.	This program was transferred from being a government policy to being a policy of the states³⁷. It also encompassed the medical professionals of the PROVAB, in which the characteristics were adjusted to the parameters of the PMM. Some results identified: (1) improvement of the basic healthcare structure: construction of 1,577 UBSs, two River UBSs in the Amazon region, refurbishment of 9,011 UBSs; (2) medical training: 47 new medicine courses opened (24 in federal institutions), increasing the number of places by 65%³⁷ - we cannot yet comment on the change in the profile of doctors since none have yet emerged from the new curriculum; (3) the PMMB program reached 3,785 municipalities in less than two years, recruiting 14,462 doctors (1,846 Brazilian and 1,616 foreign doctors) from 49 countries³⁷.

	Challenge			Areas of the political initiative involved
Political initiative	Geographical distribution	Distribution by level	Availability of doctors	Training of doctors	Inflow and outflow	Correct inadequate distribution and inefficiency	Regulation of the private sector
Rondon Project (curriculum internship in areas of difficult access and services in expansion) - 1968 - 1989 and 2005 - present	x	primary				educational*
PISUS (payment for production, formal contract, appropriate physical installations and accommodation) - 1993 - 4	x	primary				financial, and personal and professional support*
PITS (financial incentives, continued education, appropriate work conditions, accommodation, food and transport) - 2001 - 4	x	primary				financial, educational and personal and professional support*
Telessaúde (`Tele-health’ - distance care and distance education) - 2007 - present	x	primária				professional, personal and educational support*
Pró-Residência (grants for residencies, and opening of residencies) - 2009 - present	x	specialists	x	x		financial and educational*
FIES (amortization of undergraduate student debt) - 2011 - present	x	primary				financial*
PROVAB (grants, distance and in-person supervision, opportunity for specialization and additional points gained in selection process for residency) - 2011 - present	x	primary				personal and professional, educational and financial
More Doctors (Mais Médicos) Program (improvement in infrastructure of the network, grants, opportunity for training and qualification and curriculum change, increased vacancies and recruitment) - 2013 -present	x	primary	x	x	x	regulatory/administrative (including bilateral agreements), educational, financial, personal and professional support*

Location of search	Specifications of search	Criteria for inclusion and exclusion of documents
PubMed and BVS	Systematic search, in January 2016, in the databases of the Virtual Health Library (BVS), and PubMed of the National Library of Medicine, where the scientific documents were identified based on a search using the following terms: (physician OR physicians OR doctor OR doctors OR health professionals OR workforce OR health workers OR manpower) AND (geographical OR imbalance OR rural OR remote OR suburban OR scarcity OR lack) AND Brazil – details of the search are available on request. Finally, documents identified as relevant (related to the structure of the problem under study or to a specific strategy) as a result of the initial references selected, were included.	(i) The material should be about medical professionals, whether or not including other professionals; (ii) when about more than one country, it should enable information relating to Brazil to be identified in isolation; (iii) it must be available in computerized form, making possible searches for information in the text; (iv) dated 1994-2015; (v) and without language restrictions; (vi) principal subjects to include geographical availability or accessibility of healthcare human resources as principal focus of the article in one of three aspects: geographical availability / distribution of doctors; causes of scarcity or asymmetric distribution; or strategies for dealing with the problem: whether (a) describing or assessing the strategy in its implementation in Brazil, or (b) describing or assessing a strategy implemented in another country, raising considerations for its implementation in Brazil. Documents that presented data without the results of processing it or without introduction of new conclusions were excluded. The year 1994 was chosen as a cutoff due to the implementation of the Family Health Strategy (ESF). This choice is justified by the fact of healthcare being organized based on the precept of Primary Health Care (PHC)
Websites	Research on websites of the Brazilian Health Ministry (HM), International organizations (World Bank, OECD, WHO, Inter-Agency Health Information Network (Rede Interagencial de Informação para a Saúde, RIPSA), and Health Graduations Indicator Systems (Sistemas de Indicadores das Graduações em Saúde, SIGRAS), the Brazilian Federal Council on Medicine, and the Brazil Health Human Resources Observation Network (Rede Observatório de Recursos Humanos em Saúde do Brasil, ObservaRH), with a focus on the work situations that have lines of study or research on the subject in question.
Individual key advice and information sources	In parallel, key information sources were consulted to identify possible documents not included in the previous phases (items published, and the ‘gray literature’), or names of strategies that would enable a specific search on the sites described.

Location of search	Specifications of search	Criteria for inclusion and exclusion of documents
PubMed and BVS	Systematic search, in January 2016, in the databases of the Virtual Health Library (BVS), and PubMed of the National Library of Medicine. Search terms were: (physician OR physicians OR doctor OR doctors OR health professionals OR workforce OR health workers OR manpower) AND (geographical OR imbalance OR rural OR remote OR suburban OR scarcity OR lack) AND Brazil – details of the search are available on request. Documents identified as relevant (related to the structure of the problem under study or to a specific strategy) as a result of the initial references selected, were included.	(i) The material should be about medical professionals, whether or not including other professionals; (ii) when about more than one country, it should include information relating to Brazil separately from other countries; (iii) it must be available in a computerized form, making possible searches for information in the text; (iv) dated 1994-2015; (v) without language restrictions; (vi) principal subjects to include geographical availability of or accessibility to HRH as principal focus of the article in one of three aspects: geographical availability / distribution of physicians; causes of scarcity or asymmetric distribution; or strategies for dealing with the problem: whether (a) describing or assessing the strategy in its implementation in Brazil, or (b) describing or assessing a strategy implemented in another country, with relevance for its implementation in Brazil. Documents that presented data without the results of processing it or without introduction of new conclusions were excluded. The year 1994 was chosen as a cut-off point as it corresponds to the implementation of the Family Health Strategy (ESF). This choice is justified by the fact of health care was meant to be organized along the principles of Primary Health Care (PHC)
Websites	Research on websites of the Brazilian Ministry of Health (MoH), International organizations (World Bank, OECD, WHO), Inter-Agency Health Information Network (Rede Interagencial de Informação para a Saúde - RIPSA), and Health Graduations Indicator Systems (Sistemas de Indicadores das Graduações em Saúde - SIGRAS), the Brazilian Federal Council on Medicine, and the Brazil Health Human Resources Observatories Network (Rede Observatório de Recursos Humanos em Saúde do Brasi - ObservaRH), with a focus on lines of study or research on the subject in question.
Individual key advice and information sources	In parallel, key informants were consulted to identify documents not included in the previous phases (published, and the ‘grey literature’), or strategies that would enable an additional specific search.

Question	Category	Subcategory
What are the challenges identified by policy makers and managers in ensuring geographical availability and accessibility to doctors within the SUS system?	Stock of qualified healthcare human resources and their characteristics in terms of distribution	Scarcity of professionals; distribution between rural and urban; distribution of professionals between public and private; among other aspects.
What are the determinant factors in these challenges?	Education sector and dynamics of the market	Number of graduate positions available, number of specialization positions, planning in the form in the training of healthcare professionals, number of retirements, loss to the private sector, unemployment, emigration, double employment, inefficacious contracting procedures; among other aspects.
What strategies and areas of policy interventions were used to correct the challenges faced by policy makers and managers at the national level to ensure geographical availability and accessibility for doctors within the SUS system?	Areas of political strategies	Policies surrounding training of healthcare professionals, policies surrounding flows of entry and exit, among other aspects.

Question	Category	Subcategory
What are the challenges identified by policy makers and managers in ensuring geographical availability and accessibility to physicians within the SUS system?	Stock of qualified HRH and their characteristics in terms of distribution	Scarcity of professionals; distribution between rural and urban; between public and private; among other aspects.
What are the determinant factors in these challenges?	Education sector and dynamics of the labour market	Number of graduate positions available, number of specialization positions, planning of the training of health care professionals, number of retirements, losses to the private sector, unemployment, emigration, double employment, ineffective contracting procedures, among other aspects.
What strategies and areas of policy interventions were used to correct the challenges faced by policy makers and managers at national level to ensure geographical availability and accessibility to physicians within the SUS system?	Areas of political strategies	Policies on training of HRH, policies on flows of entry and exit, among other aspects.

Political Intervention	Aim/Description	Important Points
Rondon Project: 1968 - 1989, and 2005 - present	This program aimed to promote service internships for university students⁴⁸ and consequently bring students to the work in areas of difficult access and health services that were expanding³⁶. In 2005 it was re-launched and now has representatives from the Defense, Education, Health and other Ministries⁴⁹.	In its 22 years this project has served thousands of municipalities, most of them in the Center-West, Northeast and Northern Regions of Brazil³⁶.Some 350,000 university students and 13,000 teachers have taken part in the project^35,36. The literature that was analyzed does not indicate the reasons why it was terminated. Since the re-launch of the project, it has involved 1,900 higher education institutions and carried out 69 operations in 854 municipalities in 23 States⁵⁰.This intervention focused on the area of policies directed to training and qualification, and did not coordinate with other areas of political interventions. Although the literature indicates that for a student to live in a less accessible environment widens his choice for future work17, no data was found for any monitoring of these students after graduation.
PISUS: 1993 - 1994	The objective was to take into the interior of each region or state a minimum health team comprising a Community Health Agent, Nurse and Doctor to support one health service35.It was organized in four sub-programs: (i) first aid units, (ii) establishment of a doctor in a region of the interior (at least one to establish fixed residence in the participating municipality), (iii) interiorization of the nurse, and (iv) the Community Agents³⁶. It offered appropriate physical facilities, accommodation for nurses and doctors, payment for production, and a formal contract executed by the municipal manager using funds passed through from the Health Ministry^35.	This program reached 398 municipalities³⁵. Since it lasted only for a short time, the lack of information about the reasons why it was terminated prevents any future action in this area from correcting possible fragilities. This is a factor that inhibits continuity of political initiatives.
PITS: 2001 - 2004	This aimed to encourage placement of qualified health professionals in municipalities with proven shortage of medical and health resources⁵¹, distant from state capital cities, and also help expand basic healthcare and the Family Health Program (PSF)³⁶. Coordinated at a national level by the Health Ministry, it adopted the same strategy as the PSF, and made use of financial incentives, continuing education for participating professionals, and professional and personal support through appropriate work conditions (equipment and inputs), and accommodation, food and transport for them to carry out their activities³⁶.The participating doctors did the specialization course in Family Health⁵².	During the period, the program was applied for 421 health professionals, 181 of them doctors, in 300 municipalities³⁵. It can be seen that this program had greater articulation of the strategies to motivate the health professional, but as with the previous program (PISUS), above, it was also not possible to find out the reasons for its termination.
Telessaúde: 2007 - present	This was a strategy that was a part of the National Permanent Health Education Policy implemented as one of the actions of the Mais Saúde (More Health) program^55,56. Its objective is to orient qualification and development of health human resources and improvement of care and management in basic healthcare in the SUS^55,57. It integrates teaching and service, also providing distance healthcare and distance education, through ICT⁵⁵.	This strategy has been related to the attempt to improve the number of health professionals who establish permanent residence in remote areas, since it helps to reduce the possible sensation of isolation and clinicalin security^55,57. Studies point to the contributions of ‹tele-health› in the sector^58,59, demonstrating that technology can be a strong ally in exchange of knowledge and training of professionals of the network. This is an area that is expanding, and likely to be explored in the future in the policies relating to health human resources.
Pró-Residência: 2009 - present	An inter-sector measure between the Health Education Ministries. It aims, through award of grants, and training of specialists in basic and priority areas for some regions of the country (North, Northeast and Center-West), to provide support and opening of new residency programs based on the need of the region⁶⁰.	Since local and regional shortages in specialists in certain areas of medicine are diagnosed and reported, this initiative has the potential to help in the choice of the professional’s activity, thus helping both the market and the doctor’s career.
FIES: 2011 - present	In 2011 the government made it possible for doctors whose graduation had been financed by the FIES to pay off their debts by working in the teams of the Family Health Strategy (ESF) in areas where there was a shortage of doctors. For each month worked, the deduction was 1% of the debtor balance⁶¹.	It has contributed to expanding the number of doctors in the country, enabled various students to conclude their course through this financing. Linking the student debt to the professional working in the SUS is one more way of expanding the store of doctors in the service and contributing to a reduction of the disparities in health.
PROVAB: 2011 - present	This aims to provide Basic Healthcare and Family Health Strategy teams with nurses, dentists and doctors, in areas that are remote and more vulnerable (riverbank populations, Quilombo settlements, new country settlements, indigenous people, etc.), thus achieving integration between teaching, service and community. The professionals receive a study grant paid by the Federal Government, distance and in-person supervision, and the opportunity to carry out a specialization course focused on basic healthcare offered by universities participating in the UNA-SUS⁶⁰.At the end of the year, the doctors can receive up to 10% of the total 100% marking the points system of the process of selection for medical residency³⁵.	The number of participants increased from 381 in 2012 to over 3,300 in 2013, distributed between 1, 157 municipalities, of which 573 are located in the Northeastern Region⁶². In 2015 the PROVAB was integrated into the PMM (‘Mais Medicos’) Program.
‘More Doctors’ Program (PMM): 2013 - present	This program aims to train doctors and take them to regions where health professionals are scarce or absent⁶⁵. It is structured in three parts:(1) improvement of basic healthcare structure - improvement in infrastructure of the RAS, focused on Basic Health Units (UBSs); (2) medical training, changes in graduation - in medical residency and training of specialists, such as, for example, implementation of the new DCN and expansion of graduation courses in the public and private sectors; and (3) the emergency provision aspect - the program provides doctors on an emergency basis in vulnerable areas (by recruitment of Brazilian and foreign doctors either individually or through a bilateral agreement made with the government of Cuba)³⁷. The participant receives a monthly grant and cost support for the facility³⁷, of which the amounts are higher for those that travel further to more remote areas⁷.	This program was transferred from being a government policy to being a policy of the states³⁷. It also encompassed the medical professionals of the PROVAB, in which the characteristics were adjusted to the parameters of the PMM. Some results identified: (1) improvement of the basic healthcare structure: construction of 1,577 UBSs, two River UBSs in the Amazon region, refurbishment of 9,011 UBSs; (2) medical training: 47 new medicine courses opened (24 in federal institutions), increasing the number of places by 65%³⁷ - we cannot yet comment on the change in the profile of doctors since none have yet emerged from the new curriculum; (3) the PMMB program reached 3,785 municipalities in less than two years, recruiting 14,462 doctors (1,846 Brazilian and 1,616 foreign doctors) from 49 countries³⁷.

Political Intervention	Aim/Description	Important Points
Rondon Project: 1968–1989, and 2005–present	This program aimed to promote service internships for university students⁶ and consequently bring students to work in areas of difficult access and where health services were expanding³⁶. In 2005 it was re-launched and now involves the Defence, Education, Health and other Ministries ⁴⁷.	In its 22 years this project has served thousands of municipalities, most of them in the Centre-West, Northeast and Northern Regions³⁶. Some 350,000 university students and 13,000 teachers have taken part in the project^35,36. The literature does not indicate the reasons why it was terminated. Since the re-launch of the project, it has involved 1,900 higher education institutions and carried out 69 operations in 854 municipalities in 23 States⁴⁸. This intervention focused on the area of policies directed to training and qualification, and did not coordinate with other areas of political interventions. Although the literature indicates that for a student to live in a less accessible environment widens his choice for future work¹⁷, no information was found on monitoring of these students after graduation.
PISUS: 1993–1994	The objective was to take into the interior of each region or state a minimum health team comprising an ACS, a nurse and a physician to support one health unit³⁵. It was organized in four sub-programs: (i) first aid units, (ii) establishment of a physician in a region of the interior (at least one residing in the participating municipality), (iii) recruitment of nurses, and (iv) ACS³⁶. It offered appropriate physical facilities, accommodation for nurses and physicians, payment by performance, and a formal contract with by the municipality using funds from the Ministry of Health ³⁵.	This program reached 398 municipalities³⁵. Since it lasted only for a short time, the lack of information about the reasons why it was terminated prevents any future action in this area from correcting possible fragilities. This is a factor that inhibits continuity of political initiatives.
PITS: 2001–2004	This aimed to encourage placement of qualified health professionals in municipalities with a proven shortage of medical and health resources⁴⁹, distant from state capital cities, and to help expand primary health care and the PSF⁴⁹. Coordinated at a national level by the Ministry of Health, it adopted the same strategy as the PSF, and used financial incentives, continuing education, and professional and personal support through improved working conditions (equipment and inputs), and accommodation, food and transport for them to carry out their activities³⁶. The participating physicians did a specialization course in Family Health⁵⁰.	During the period, the program was applied to 421 health professionals, 181 of them physicians, in 300 municipalities³⁵. This program had greater articulation of the strategies to motivate health professional, but as with the previous program (PISUS), it was also not possible to identify the reasons for its termination.
Telessaúde: 2007–present	This strategy was part of the National Permanent Health Education Policy implemented as one of the actions of the More Health program^51,52. Its objective is to orient qualification and development of HRH and improvement of care and management in PHC in the SUS^51,53. It integrates teaching and service, also provides distance health care and distance education, through ICT⁵¹.	This strategy has been related to the attempt to improve the number of health professionals who establish permanent residence in remote areas, since it helps to reduce the possible sensation of isolation and clinical insecurity^51,53. Studies point to the contributions of ‘tele-health’ in the sector^54,55, demonstrating that technology can be a strong ally in the exchange of knowledge and training of professionals of the network. This is an area that is expanding, and likely to be in developed the future in the policies relating to HRH.
Pró-Residência: 2009–present	An inter-sectoral measure between the Ministries of Health and Education. It aims, through grants and training of specialists in basic and priority areas for some regions of the country (North, Northeast and Centre-West), to provide support and opening of new residency programs based on the needs of the region⁵⁶.	Since local and regional shortages of specialists in certain areas of medicine are diagnosed and reported, this initiative has the potential to help in the choice of the professional’s activity, thus both responding to demand and helping the physician’s career.
FIES: 2011–present	In 2011 the government made it possible for physicians whose education had been financed by the FIES to pay off their debts by working in a team of the ESF in areas where there was a shortage. For each month worked, the deduction was 1% of the debt balance⁵⁷.	It has contributed to expanding the number of physicians in the country, by enabling students to conclude their course thanks to this financing. Linking the student debt to work in the SUS is one more way of expanding the stock of physicians and of contributing to a reduction of the disparities in health.
PROVAB: 2011–present	This aims to provide PHC and ESF teams with nurses, dentists and physicians, in areas that are remote and more vulnerable (riverbank populations, Quilombo settlements, new country settlements, indigenous people, etc.), thus achieving integration between teaching, service and community. The professionals receive a study grant paid by the Federal Government, distance and in-person supervision, and the opportunity to access a specialty course focused on PHC offered by universities participating in the UNA-SUS⁵⁶. At the end of the year, the physicians can receive up to 10% of the total 100% mark in the points system of the process of selection for medical residency³⁵.	The number of participants increased from 381 in 2012 to over 3300 in 2013, distributed between 1157 municipalities, of which 573 are located in the Northeastern Region⁵⁸. In 2015 the PROVAB was integrated into the PMM.
More Doctors Program (PMM): 2013–present	This program aims to train physicians and take them to regions where health professionals are scarce or absent⁵⁹. It is structured in three parts: (1) improvement of PHC structure – improvement in infrastructure of the RAS, focused on Basic Health Units (UBSs); (2) medical training, changes in pre-service education – in medical residency and training of specialists, such as the implementation of the new DCN and expansion of medical programs in the public and private sectors; and (3) the emergency provision aspect – the program make physicians available on an emergency basis in vulnerable areas (by recruitment of Brazilian and foreign physicians either individually or through a bilateral agreement made with the government of Cuba)³⁷. The participant receives a monthly grant and cost support for the facility³⁷, of which the amounts are higher for those in more remote areas⁷.	This program evolved from being a government policy to being a policy of the states³⁷. It also encompassed the professionals of the PROVAB, whose characteristics were adjusted to the parameters of the PMM. Some results were: (1) improvement of the PHC structure: construction of 1577 UBSs, two River UBSs in the Amazon region, refurbishment of 9011 UBSs; (2) medical training: 47 new medicine programs (24 in federal institutions), increasing the number of places by 65%³⁷ – we cannot yet comment on the change in the profile of physicians since none have yet graduated from the new curriculum; (3) the PMMB program reached 3785 municipalities in less than two years, recruiting 14462 physicians (1846 Brazilians and 12616 foreign physicians) from 49 countries³⁷.

	Challenge			Areas of the political initiative involved
Political initiative	Geographical distribution	Distribution by level	Availability of doctors	Training of doctors	Inflow and outflow	Correct inadequate distribution and inefficiency	Regulation of the private sector
Rondon Project (curriculum internship in areas of difficult access and services in expansion) - 1968 - 1989 and 2005 - present	x	primary				educational*
PISUS (payment for production, formal contract, appropriate physical installations and accommodation) - 1993 - 4	x	primary				financial, and personal and professional support*
PITS (financial incentives, continued education, appropriate work conditions, accommodation, food and transport) - 2001 - 4	x	primary				financial, educational and personal and professional support*
Telessaúde (`Tele-health’ - distance care and distance education) - 2007 - present	x	primária				professional, personal and educational support*
Pró-Residência (grants for residencies, and opening of residencies) - 2009 - present	x	specialists	x	x		financial and educational*
FIES (amortization of undergraduate student debt) - 2011 - present	x	primary				financial*
it continues
PROVAB (grants, distance and in-person supervision, opportunity for specialization and additional points gained in selection process for residency) - 2011 - present	x	primary				personal and professional, educational and financial
More Doctors (Mais Médicos) Program (improvement in infrastructure of the network, grants, opportunity for training and qualification and curriculum change, increased vacancies and recruitment) - 2013 -present	x	primary	x	x	x	regulatory/administrative (including bilateral agreements), educational, financial, personal and professional support*

	Challenge			Areas of the political initiative involved
Political initiative	Geographical distribution	Distribution by level	Availability of physicians	Training of physicians	Inflow and outflow	Correct imbalanced distribution and inefficiency	Regulation of the private sector
Rondon Project (curriculum internship in areas of difficult access and services in expansion) – 1968–1989 and 2005–present	x	primary				educational*
PISUS (payment by performance, formal contract, adequate physical installations and accommodation) – 1993–4	x	primary				financial, and personal and professional support*
PITS (financial incentives, continued education, adequate working conditions, accommodation, food and transport) – 2001–4	x	primary				financial, educational and personal and professional support*
Telessaúde (Tele-health – distance care and distance education) – 2007–present	x	primary				professional, personal and educational support*
Pró-Residência (grants for residencies, and opening of residencies) – 2009–present	x	specialists	x	x		financial and educational*
FIES (amortization of undergraduate student debt) –2011– present	x	primary				financial*
PROVAB (grants, distance and in-person supervision, opportunity for specialization and additional points gained in selection process for residency) – 2011– present	x	primary				personal and professional, educational and financial
More Doctors Program (improvement in infrastructure of the network, grants, opportunity for training and specialization and curriculum change, increased of number of positions and recruitment) – 2013– present	x	primary	x	x	x	regulatory/administrative (including bilateral agreements), educational, financial, personal and professional support*

[1] Collaborations

APC Oliveira worked on the conception of the study and methodology, collection and analysis of the data, structuring and writing of the article and revision of the drafting in all the versions including the final one; M Gabriel worked on collection and analysis of the data, structuring and writing the article in all the versions and revision of the final draft; and MR Dal Poz and G Dussault worked on the design of the study and revision of the drafting of the article in all the versions including the final one.

Brasil

Brasil

Challenges for ensuring availability and accessibility to health care services under Brazil’s Unified Health System (SUS)

Abstract