The scope of practice of primary health care physicians in rural and urban areas in Brazil

This study aimed to identify differences in the scope of practice of primary care physicians and find the main factors associated with expanded practice in rural and urban areas of Brazil. Data from an online survey with 2,277 primary care physicians, conducted between January and March 2016, were used. Differences regarding activities and procedures performed by physicians per area were verified using Kruskal-Wallis/Dunn’s post hoc and chi-square tests. Multivariate linear regression analyses were done using a bootstrap technique to identify the main factors associated with an expanded scope of practice. Regardless of the location, the results showed that the practices of the primary care physicians are below their competences. Rural physicians performed a higher number of procedures and activities compared with their peers from intermediate and urban municipalities. Within the overall sample, the variables related to a broader scope of practice included: male gender, work in rural municipalities, participation in training and continuing education programs and consultation of clinical protocols, articles and books. This study contributes with evidence that the medical scope of practice varies


Introduction
Primary healthcare (PHC) in Brazil is crucial to the Unified National Health System (SUS) 1 . The consolidation of PHC over the past decades is one of the major advances made by SUS as a public policy and universal system. Different policies and programs contributed to the expansion of PHC. The adoption of the Family Health Program in 1994 can be highlighted as responsible for changing and reorganizing the model of care. In 2006, it became known as the Family Health Strategy (FHS) after the publication of the National Policy on Primary Care (PNAP, in Portuguese). Although under strong recent threats (some reported in the discussion), FHS is considered the main PHC model in Brazil. Composed by a multiprofessional team of physicians, nurses, nurse technicians and community health agents, it has reached more than 40,000 teams 1,2,3 . Physicians play an important role in this team, however, attracting and retaining them in PHC to rural, remote and unsafe areas of urban centers is a continuous challenge 4 .
Access to PHC is strongly related to health policies, geographic location of the place of residence and workforce availability 5 . Shortage and maldistribution of health professionals are among the main barriers. Providing enough professionals, at the right time, in the right places, and with the right skills is essential to ensure health access to the population 5,6 . The difficulty in reducing inequality of access to care in large countries, such as Brazil, is well known. Policymakers worldwide are under constant pressure to ensure health access to the population and find innovative ways to deliver services with less cost and without compromising the quality 4,5,6 .
In Brazil, the latest, and one of the most impactful strategies adopted is the More Doctors Program (PMM, in Portuguese) implemented in 2013 to reduce physician shortage and health inequalities in underserved areas. It is a multidimensional program with three main components: (1) investments to improve the infrastructure of health units; (2) reforms and expansion of medical undergraduate courses and residency programs focused on PHC; and (3) emergency provision of physicians in most needed areas 7 . Concerning the third component, one of its boldest initiatives was the recruitment of over 10,000 foreign physicians, mostly from a cooperation agreement established with Cuba via the Pan American Health Organization (PAHO) 8 . However, at the end of 2018, the newly elected Federal Government ended the agreement, leading Cuban physicians to return to their country and, consequently, leaving behind a large and vulnerable population, mainly in rural, remote and peripheral urban areas, unassisted. This sudden departure caused a shortage of physicians and a change in the professional profile in several places, left the program with no investment 8 . In 2019, the government launched the Doctors Through Brazil program, with the expectation to replace the PMM. The new program focuses on providing physicians to rural and remote areas and does not include urban and peripheral areas; components 1 and 2 of the original program were also removed 8 .
To address the shortage of health professionals, amendments in the legislation that regulates their scope of practice have been carried out since the early 1970s in countries such as Canada and the United States 9,10 . The scope of practice defines the parameters of a profession; in practical terms, it describes the set of activities and functions that a professional is qualified to perform based on education, training, competence and regulation 11,12 . Many of these regulatory amendments include a comprehensive review of the health professionals' scope of practice, seeking to expand and optimize their practice by balancing professional competences and practice with population and health system needs 9,10 .
In health care, the profession scope of practice is determined and restricted by law. In Brazil, the physician's legal scope of practice is defined by Act n. 12,842/2013, which attributes to physicians a set of exclusive diagnostic, prescriptive and therapeutic activities 13 . The definition of scope of practice, however, goes beyond the legal field. Several other key determinants for a health professional's scope of practice exist, such as their education/training credentials and competencies, which can differ in levels, standards, and duration, impacting on scope of practice 12,14,15 . In Brazil, the educational component of PMM was responsible for the implementation of curricular guidelines, which included at least 30% of medical undergraduate courses in PHC 7,8 . The Brazilian Society of Family and Community Medicine also launched a new competency-based curriculum for graduate programs to help as a guide for better preparing physicians for practice in PHC 16 . Higher education institutions have, however, autonomy over their curriculum, leading to high heterogeneity in approaches to PHC contents, consequently leading to different practice patterns. In addition to formal education, the avail-Cad. Saúde Pública 2021; 37(9):e00211520 ability of other modalities of training is also considered important in determining scope of practice. Continuing education programs are a good example due to bringing knowledge closer to practice 17 .
Sociodemographic factors such as age may also play an important role in scope of practice. Older physicians tend to have more practice experience, whereas younger physicians can be more up to date on new drugs, technologies and procedures. Personal factors such as lifestyle, background, and personal interests, are also known to influence practice 14,15 . Finally, scope of practice is also strongly determined by the location of practice, being driven by population size, demands, characteristics, geographic factors, isolation, socioeconomic status, availability of health services, supplies, professionals, among others 14,18 .
Expanded scope of practice among PHC physicians working in rural and remote areas has been observed in international literature. Physicians working in these areas often develop a broader range of skills in response to population needs, a lack of professionals, services and referral opportunities. Unlike in urban areas, general practitioners and family physicians are often the only medical professionals available in rural municipalities 19,20,21,22,23 .
Understanding the differences between rural and urban physicians' scope of practice is an essential step in searching for ways to ensure universal access to healthcare. Comprehension of practice in different locations enables policymakers to offer better support to physicians and provide targeted resources and training for enhancing competencies in medical practice 22 . Besides, promoting an expanded scope of practice is expected to contribute to better retention of physicians in most needed areas, reducing costs, referral rates and inequalities in access to healthcare 5,14,19,23 .
In Brazil, few studies focus on this topic. The purpose of this study was to identify differences in PHC physicians' scope of practice and identify the main factors associated with expanded practice in rural and urban areas in Brazil.

Study design
Data from a major exploratory cross-sectional study on the regulation of health professionals in Brazil were; the survey was carried out by Human Resources for Health Observatories from the Federal University of Minas Gerais (UFMG) and the State University of Rio de Janeiro (UERJ) 24 . The collection took place between January and March 2016, through a self-administered questionnaire since this type of instrument is widely used in studies that aim to measure the scope of practice 14,20,21,25 .
The sample was reached through convenience from a list of physicians enrolled in the Family Health Specialization Program and other short-term courses focused on PHC offered by the Open University System of SUS (UNA-SUS, Portuguese). The choice of this database was based on the large number of physicians registered and the availability of email addresses, which are essential for making the research feasible. The questionnaire was mailed to all 17,536 physicians registered. In total, 4,218 physicians consented to participate, of which 2,277 responses were considered for the present analysis (physicians who reported working in PHC facilities at the time and answered the question concerning their scope of practice).

Definition of practice location
To meet the objectives of this article, respondents were stratified according to their practice location, considering the classification and characterization of rural and urban spaces, proposed by the Brazilian Institute of Geography and Statistics (IBGE) 26 . This proposal defines a rural-urban typology that considers first the demographic density and population sizes to classify the municipalities into rural, intermediate, and urban. This study then considers the location of the municipalities in relation to major urban centers to classify rural and intermediate municipalities adjacent to urban centers of higher hierarchy from those that are remote (or further away from these centers). IBGE defines a final classification of five categories: (1) rural remote, (2) rural adjacent, (3) intermediate remote, (4)

Instrument
The development of the instrument involved different steps 25: interviews with key informants, literature review 14,21,22,27 , and consultation of PHC standards and technical manuals -Proceduresfrom the Brazilian Ministry of Health 28 . The survey included sociodemographic variables (gender, age, nationality, year and country of graduation); work-related variables (workplace and experience in PHC); and support resources for practice (use of telehealth, participating in training and continuing education programs and consulting clinical protocols, articles and books).
To identify scope of practice, a list of 49 activities/procedures was presented to the respondents, for which they were asked to indicate if they practiced the procedure or activity in their work unit, and if not, if they knew how to perform them. The number of procedures/activities performed was considered as a proxy of an enhanced scope of practice of PHC physicians. The 49-items list was classified into (i) invasive/surgical procedures, and (ii) clinical activities, considering the appropriate Medical Act 16 (Box 1).

Data analysis
Sociodemographic variables and scope of practice items were stratified according to the ruralurban typology. Calculation of absolute and relative frequencies was done for categorical variables and measures of central tendency (mean, standard deviation, and median) for continuous variables. Nonparametric Kruskal-Wallis/Dunn's post hoc test was used to verify the differences regarding the groups of activities/procedures (invasive/surgical procedures and clinical activities) that respondents performed and knew how to perform since the data did not present a normal distribution (Shapiro-Wilk test). Differences regarding the 49-items by location category (rural remote, rural adjacent, intermediate, and urban) were calculated by the chi-square test.
Nonparametric bootstrap linear regression model with 4,000 repetitions was used to investigate the factors associated with an expanded scope of practice by category. At this stage, the rural remote and rural adjacent categories were aggregated into rural, resulting in four models, general (overall sample), rural, intermediate, and urban. First, we performed univariate analyses using the total of activities and procedures performed as a dependent variable and sociodemographic and support resources as independent variables. Variables with a p-value < 0.2 were included for the subsequent multivariate analysis. From the initial models of multivariate analysis, the variables whose p-values were not significant were removed one by one until all variables were within the desired significance level. We used 95% confidence intervals (95%CI) and 0.05 as the level of significance. All analyses were done using R statistical software (http://www.r-project.org).
In accordance with Resolution n. 466/2012, of the Brazilian National Health Council, due to the participation of human subjects, this study was submitted to the Ethics Research Committee of UERJ, and approved under the number 46779115.5.0000.5260, on September 29, 2015. Table 1 describes the study population according to the four municipality categories. Most respondents (63.9%) were working in Urban municipalities, followed by 24.4% in rural adjacent, 9.1% in intermediate, and 2.6% in rural remote municipalities. This distribution approaches the proportion of physicians working in PHC facilities in the same year of the survey, according to data from the National Register of Health Facilities (CNES). Concerning the geographic regions of the respondents, except for urban physicians, most were from the Northeast of the country, especially rural adjacent physicians (57.2%). Regarding urban physicians, 41.9% were from Southeastern Brazil.

Box 1
List of the activities and procedures included in the study (N = 49). More than half of the respondents were foreigners (55,4%), mostly from Cuba (89%). 61% graduated outside Brazil, from which 82.5% in Cuba. There was a higher concentration of foreigners in rural remote (97.7%) and rural adjacent (74.7%), with a predominance of Brazilian physicians only in urban municipalities (55.5%). The proportion of physicians according to gender was well distributed for all categories, except for rural remote physicians, where 64.6% were female. This same category had a slightly higher mean age than others (44.9). The mean time of graduation in years was 16.3 between for urban physicians and 20.2 for rural remote physicians. The years of experience in PHC ranged from 10.4 to 12.6 years between urban and rural remote physicians.

CLINICAL ACTIVITIES INVASIVE/SURGICAL PROCEDURES
Cad. Saúde Pública 2021; 37(9):e00211520 Table 1 Physician's sociodemographic characteristics according to rural-urban typology (Brazil, 2017 35.7%) when compared to urban physicians (69.5%). As for participating in training and continuing education programs, the proportion of respondents ranged from 45% to 58.8% between rural remote and urban physicians. Finally, consultation of clinical protocols, articles, and books presented a smaller variation between the categories, with the highest proportion among rural remote physicians (33%). Table 2 presents the mean, standard deviation (SD) and median of the number of activities and procedures that the respondents claimed to perform and know how to perform, considering the total items, and the groups invasive/surgical procedures and clinical activities. Respondents from all locations informed to know how to perform a higher mean number of procedures and activities (35.9, SD = 10.9) than they actually performed in the health facility (20.7, SD = 9.1). The same was observed concerning invasive/surgical procedures and clinical activities, for which respondents declared practicing a lower number of items, compared with the total they declared to know how to practice.
The mean of the total of procedures and activities that the respondents declared to perform and know how to perform was significantly lower among urban physicians compared to the other three categories (p < 0.001). The same was observed for clinical activities.

Table 2
Mean, standard deviation (SD) and median of activities and procedures that respondents declared to practice and know how to practice, according to the groups and the rural-urban typology (Brazil, 2017).  Regarding invasive/surgical procedures, rural remote and adjacent physicians reported performing a higher mean than their peers from urban and intermediate municipalities (p < 0.001). The practice of these types of procedures showed, however, to be low in all categories. The highest mean was observed among physicians working in rural remote municipalities, whose reported mean was 7.2 (SD = 4.8) out of 18 procedures (Table 2). Table 3 illustrates the proportion of the 49 procedures and activities listed by practice location. The results showed a significant variation in the proportion of rural and urban physicians. Respondents from rural remote and adjacent municipalities showed a higher proportion for most of the items, especially when compared with urban physicians, presenting significant differences for 34 of the items listed.

Table 3
Proportion of physicians who performed the activities and procedures (N = 49), according to the rural-urban typology (Brazil, 2017).  Invasive/surgical procedures presented the lowest proportions. The only item performed by over 50% of the total of respondents was "ear wax removal". Even between rural remote and adjacent physicians who presented the highest proportions, less than 60% practiced procedures such as "cyst, lipoma and nevus removal", "corneal or conjunctival foreign body removal" and "epistaxis cauterization (nasal bleeding)". The highest proportions (over 60% up to 69.6%) for both rural remote and rural adjacent physicians were "suture", "ear wax removal" and "local anesthetics infiltration". Concerning only rural remote, we can also highlight "ear foreign body removal", performed by 69.6%, and "pap test" by 69.1%). Regarding urban physicians, the only procedure performed by over 50% was "ear wax removal" (54.8%).
Given the results described above, we sought to verify which explanatory variables were associated with practicing a higher number of procedures and activities by category. Table 4 presents the results of four final regression models. Considering all respondents, we found that the variables associated with an expanded scope of practice were: work in rural municipalities, male gender, participa-Cad. Saúde Pública 2021; 37(9):e00211520 tion in training and continuing education programs, and consultation pf clinical protocols, articles, and books. Among the rural respondents, the factors associated with an expanded practice were: being graduated outside Brazil, male gender, less time since graduation, more experience in PHC, and consultation of clinical protocols, articles, and books. For the intermediate model, the only variables that explained a higher practice were male gender and consultation of clinical protocols, articles, and books. Finally, considering the urban physicians, the factors associated with an expanded SOP were: male gender, telehealth usage, and participation in training and continuing education programs (Table 4).

Discussion
This study sought to identify the variation of PHC physicians' scope of practice in Brazil, according to the municipality's rural-urban typology and the main factors associated with an expanded practice. The results showed that the variables related to a broader practice included: work in rural municipalities, male gender, participation in training and continuing education programs, and consultation of clinical protocols, articles, and books.
The large proportion of foreign physicians is notable in the sociodemographic characteristics of the respondents and can be explained by the period when the survey was conducted. At that time, over 10,000 PHC physicians participating in the PMM were from Cuba 29 . This scenario, however, has changed; at the end of 2018, with a newly elected federal government, approximately 8,000 Cuban physicians left the country, leaving behind a large and mostly vulnerable population, mainly Table 4 Multivariate linear regression models for the total number of activities and procedures. from rural and remote areas without medical assistance 8 . The government, since then, attempted to provide physicians in these areas. At first, they sought to attract only physicians who were certified in Brazil. However, with the difficulty in replacing the Cuban physicians, continuous shortage and high turnover rates 30 , the government recently considered the inclusion of about 1,900 of Cubans that remained in the country 31 .

Variables
The results suggest that physicians were practicing below their competencies since they reported to know how to perform more activities and procedures than they performed in their work unit. The same tendency was observed in a similar study with physicians from the PMM 32 . International studies have been reporting the decline of PHC physicians' scope of practice 15,33 . These phenomena go against the principle of the integrality of PHC, which reinforces that comprehensive care and a broader practice are fundamental to achieve better health outcomes 34 .
Physicians from all categories practiced a low number of invasive/surgical procedures. Experiences of minor surgeries in PHC reported in previous studies point up several benefits, such as greater comprehensive care, better pre-and post-procedure follow-up, greater patient satisfaction, better cost-effectiveness, reduced waiting for lines in secondary care, good results and fewer complications 34,35 . Bousquat et al. 36 found that the shortness of equipment and material observed in PHC units in Brazil limits health professionals' scope of actions and capacity to respond to population health problems.
In the present study, similar to others 14,18,19,20,21 , rural physicians reported having a broader scope pf practice, especially when compared to urban ones. The development of a higher number of skills and an expanded scope in rural and remote areas can be explained due to the lack of health services and professionals to refer and share functions when needed 14 . Also, rural areas tend to have fewer PHC physicians. In Brazil, a Primary Healthcare Physicians Shortage Index shows that among municipalities identified as suffering due to physician shortage, the ones with up to 10,000 inhabitants are the most affected 37 . Consequently, they may require a broader scope of practice, than their urban peers.
The persistence of strong inequalities in living conditions and access to health services associated with the high concentration of professionals and services in urban areas is well known. However, we also must consider the specificities of urban health. The access to health services can differ not only from city to city, but also among the population due to socioeconomic disparities, existence or not of services, and due to conditions of accessibility of services dependent on the location. Living conditions arising from urban dynamics have a big influence on the functioning of the health system, especially concerning PHC. Cities with more than 100,000 inhabitants are considered to have the greatest social and economic disparities and challenges concerning the consolidation and effectiveness of PHC. It is still important to consider the different urban profiles of these cities that show differences in the degree of PHC expansion 38 . Concerning the health workforce, urban areas are not immune to PHC physician shortage. Violent and peripheral urban areas are usually the most affected. The shortage and the high turnover rates of physicians in these areas can have an important effect on their practice 4 .
Factors associated with an expanded scope of practice are still poorly understood. The present study made it possible to identify different factors of PHC physicians. Male gender was the only significant in all models tested, consistent with other studies 15,34 . None of them, however, has deepened this issue. The feminization trend of the medical profession is a topic that deserves some questioning.
Less time since graduation was associated with a broader practice within rural and urban physicians. Similar studies attest that younger and newly graduated are more willing to practice an expanded scope of practice 15,32 . Only among physicians from rural municipalities, more experience in PHC had a positive association, indicating that experience is an essential attribute for rural practice. Still considering the rural model, being graduated abroad showed to be associated with practicing a more significant number of procedures and activities. This can be explained by the number of foreign physicians in this category, mostly Cuban. Medical education in Cuba is well known to have an essential emphasis on primary care, and study has shown that their performance encompasses a wide range of actions and services, consistent with the principle of comprehensiveness 39 .
Cad. Saúde Pública 2021; 37(9):e00211520 The access to support resources for practicing in PHC showed an important impact on scope of practice. Regarding the three resources tested, participation in training and continuing education programs and telehealth usage showed a positive association for an expanded practice among urban physicians, and consultation of clinical protocols, articles, and books among rural and intermediate. These results suggest that the use of support resources can be related to financial and infrastructure issues. The offer of telehealth and promotion of education activities is more feasible in more developed urban municipalities.
Encouraging and enabling the provision of telehealth and education activities in a non-urban area could favor an expanded practice between physicians and better health outcomes. Telehealth in PCH has well-known benefits, being an important strategy to the decentralization of care, reducing referral rates, improving access to specialized services in remote areas, reducing health costs and patients' travel time 40,41 . However, the results indicate that the reach of this resource, especially in rural municipalities, is insufficient. Similarly, the benefits of continuing educational programs are also consolidated, including the improvement of professional qualification and practice, an increase in quality of care, and a decrease in incorrect diagnoses and prescriptions 42,43,44 .
Ensuring the population's access to health services in Brazil has always been challenging. Since 2016, SUS has undergone several changes having the PHC as the main target. The publication of the new Brazilian National Basic Health Care Policy (PNAB, in Portuguese) in 2017, introduces, with concern, new forms of the service organization, team composition, work process, and scope of practice. The priority given to the FHS is put in check, evidenced by federal funding for the traditional primary care models, admitting teams composed of only physicians and nurses, with reduced hours and flexibility of the population coverage by each team 8,44,45 .
Concerning possible changes in scope pf practice, in 2019 the ministry of health presented a Primary Health Care Service Portfolio, establishing a list of basic and essential services to be delivered in PHC. The municipality has authority to add or remove items. The list of services has a predominance of clinical practices of individual nature, with emphasis on pathologies and procedures, in a biomedical approach. While some institutions showed to be favorable to the list, such as the Brazilian Society of Family Medicine, claiming it can contribute to a greater resolution and efficiency of services, others, as the National Health Council, argue that the list can, on the contrary, impair resolution, reduce scope of practice and favor a segmentation of minimal standards, typical of a selective primary health care 44,46 .
The present study provides important information on physicians' scope of practice, identifying regional differences in PHC practice, for rural and urban areas. Pointing out these differences in practice is important since there is a tendency by policymakers to create health strategies without recognizing the variability between practices 19 . Our findings are relevant for policymakers on healthcare professionals to develop educational and training programs and provide resources necessary to allow physicians to practice at their best level. Regarding attracting and retaining physicians in rural and remote areas -an ongoing challenge in Brazil 4,6 -, was aggravated now by the departure of Cuban physicians located mainly in these areas 30 , the comprehension of the extent of rural practice can enable to discern the clinical competencies required for practice, allowing more informed target planning of recruitment. Besides, it can contribute to incoming physicians to know what is expected from a practice perspective 19 . Some studies indicate that expanded scope pf practoce is considered an essential factor in physicians' choice for the workplace 23 .
A positive association between a broader scope of practice of health professionals, better health outcomes, lower cost and impact on retention of physicians in rural and remote areas has been observed in several studies 11,19,23,25,47 . It is undeniable that policymakers should pay attention to this subject. Despite not being the focus of the present study, it is important to emphasize that studies on practice should cover all health professionals. Especially by recognizing some procedures and activities that can, and should be, shared among them, for example between physicians and nurses. Scope of practice's law and regulations have been an active and growing area of debate within human resource for health planners. Flexibilizing and enhancing the scope of practice of health professionals flexible and enhancing it, and not only physicians, have shown to be effective in improving access to care and reducing health costs 10,11,19 . Further research including all professionals in the FHS team must be carried out in Brazil, seeking innovative ways to maximize and optimize the skills and competencies Cad. Saúde Pública 2021; 37(9):e00211520 of the entire PHC team. Teamwork presumes shared responsibilities that should be regulated in Brazil, as it has been regulated worldwide.
This study has limitations. The first, at the time of the survey, Cuban physicians represented a significant part of the PHC workforce in Brazil, especially in rural and remote municipalities. With the recent ending of the cooperation between Cuba and Brazil, this scenario has changed. Future research should evaluate the chance of scope of practice considering the differences in professional profiles. Second, we recognize that there are differences in medical training and post-graduation of all respondents, which are important determinants for scope of practice, reflecting also differences in professional skills and views on health. However, this variable was not suitable for analysis due to data quality issues. In this sense, the lack of this information could have affected the accuracy differences in scope pf practice measured. Third, being an exploratory study, the findings should be complemented by other studies, such as explanatory and qualitative studies. Fourth, the unit of analysis was the municipality, which does not permit to measure of internal differences regarding scope of practice. This is a limitation, especially when considering the urban municipalities, where there is certainly variation in practice (e.g., center x peripheral areas). Finally, we should consider the limitations of the instrument itself, as it did not include the main barriers and obstacles for performing the activities and procedures per item, which could contribute to a more accurate analysis per location.

Conclusion
The present study corroborates with evidence that medical scope of pratice varies according to location. Recognizing and detailing these differences and the factors associated with an expanded practice is relevant to determine the skills and resources required for professional practice in different areas, thus improving access to and quality of health care services. Considering that, in Brazil, primary care provided by SUS is the main contact of most of the population and a broader scope of practice of health professionals is known for its benefits, health and education policies that favor an expanded practice among PHC physicians should be encouraged.