An analysis of the Brazilian medical associations struggles confronting the More Doctors Program

Luciano Bezerra Gomes Emerson Elias Merhy About the authors

Abstracts

Buscamos analisar a agenda política das principais entidades médicas nacionais brasileiras e suas lutas em torno do Programa Mais Médicos do Ministério da Saúde do Brasil. Trata-se de pesquisa de natureza qualitativa, de nível exploratório e de caráter analítico, baseada em diversas fontes que veicularam posições dessas entidades, de maio de 2010 a dezembro de 2014, e em publicações da imprensa, de junho de 2013 a dezembro de 2014, que foram sistematizadas segundo categorias elaboradas a partir da própria análise. Identificamos que as entidades médicas brasileiras realizaram intensa atuação conjunta, integrando interesses voltados aos setores público e privado. O apogeu se deu entre junho e outubro de 2013, nas mobilizações de resistência ao Programa Mais Médicos. Entretanto, registramos que divergências em torno das lutas contra este Programa fragilizaram as articulações políticas dessas entidades que haviam sido construídas nos últimos anos.

Médicos; Sociedades médicas; Programas governamentais; Médicos graduados estrangeiros; Programas médicos regionais


We sought to analyze the political agenda of the main Brazilian national medical entities and their struggles around the More Doctors Program implemented by the Brazilian Ministry of Health. It is a research of qualitative nature, of exploratory level and of analytical character, based on several sources presenting positions of these entities, from May 2010 to December 2014, and in press publications, from June 2013 to December 2014, systematized according to categories elaborated from the analysis itself. We identified that the Brazilian medical entities performed intense joint action integrating interests directed to the public and private sectors. The apogee took place between June and October of 2013, through mobilizations of resistance to the More Doctors Program. However, we note that divergences around the struggles against this Program have weakened the political links of these entities that had been built in recent years.

Physicians; Medical associations; Governmental programs; Foreign graduate doctors; Regional medical programs


Nuestro objetivo fue analizar la agenda política de las principales entidades médicas nacionales brasileñas y sus luchas frente al programa Más Médicos del Ministerio de la Salud de Brasil. Se trata de investigación de naturaleza cualitativa, de nivel exploratorio y de carácter analítico con base en diversas fuentes que publicaron posiciones de esas entidades, desde mayo de 2010 a diciembre de 2014 y en publicaciones de la prensa, de junio de 2013 a diciembre de 2104, que han sido sistematizadas según categorías elaboradas a partir del propio análisis. Identificamos que las entidades médicas brasileñas realizaron una intensa actuación conjunta integrando intereses enfocados en los sectores público y privado. El apogeo fue entre junio y octubre de 2013 en las movilizaciones de resistencia al Programa Más Médicos. No obstante, registramos que las divergencias alrededor de las luchas contra este Programa fragilizaron las articulaciones políticas de esas entidades que se habían construido en los últimos años.

Médicos; Sociedades médicas; Programas gubernamentales; Médicos graduados extranjeros; Programas médicos regionales


Introduction

The political action of the professionals in the Brazilian National Health System (SUS) is one of its most striking aspects, as several associative organizations made relevant contributions over the decades in the struggle towards the Sanitary Reform in Brazil. Among the various professional groups, a differential is identified in relation to the role assumed by physicians, since medicine plays a central role in the way health work develops, being the profession that has presented over time greater potential to build different plans for deploying health care models11. Feuerwerker LCM. Micropolítica e saúde: produção do cuidado, gestão e informação. Porto Alegre: Editora Rede Unida; 2014.

2. Machado MH, organizadora. Os médicos no Brasil: um retrato da realidade. [livro eletrônico] Rio de Janeiro: Fiocruz; 1997.
-33. Campos GWS. Os médicos e a política de saúde. São Paulo: Hucitec; 1988..

In the last decades, however, important transformations have produced tensions in the medical work, in aspects ranging from economic interests related to medicine to micro-political relations in health work. Some of the most relevant were:

  • a considerable change in the pattern of economic accumulation in the health sector, as financial capital began to present increasing investments in the form of health insurance and managed care, leading to the constitution of logics different from those promoted by industrial capital, which made profit as more services and procedures were performed; In recent forms of organization of capital in health, this profit relation has been reversed, and it became better for its expansion that a greater number of people linked to the companies consume the least possible of the available services44. Merhy EE. Saúde: a cartografia do trabalho vivo. São Paulo: Hucitec; 2002.,55. Iriart C, Merhy EE, Waitzkin H. La atención gerenciada en América Latina. Transnacionalización del sector salud en el contexto de la reforma. Cad Saúde Pública. 2000; 16(1): 95-105.;

  • insertion of doctors in the labor market leading to a process of wage earning without proletarianization of these professionals or to a total loss of autonomy of this category, which continues to present dimensions of this work that are not able to be controlled by the employer, and whose levels of freedom are even coherent with current capitalist interests44. Merhy EE. Saúde: a cartografia do trabalho vivo. São Paulo: Hucitec; 2002., 66. Campos GWS. A saúde pública e a defesa da vida. São Paulo: Hucitec; 1991.

    7. Campos GWS. Um método para análise e co-gestão de coletivos: a constituição do sujeito, a produção de valor de uso e a democracia em instituições: o método da roda. São Paulo: Hucitec; 2000.

    8. Campos GWS. Reforma da Reforma: repensando a saúde. 3a ed. São Paulo: Hucitec; 2006.
    -109. Merhy EE. Em busca do tempo perdido: a micropolítica do trabalho vivo em saúde. In: Merhy EE, Onocko R; organizadores. Agir em saúde: um desafio para o público. 2a ed. São Paulo: Hucitec; 2002. p. 71-112.;

  • the relations of physicians with other health workers have undergone transformations, since, at the same time that physicians adapt their work to guarantee their levels of autonomy, they have also gone through disputes over the hegemony of knowledge and health services, as part of the actions that were previously exclusive to them are now developed by other professions1110. Cecilio LCO. Autonomia versus controle dos trabalhadores: a gestão do poder no hospital. Ciênc. saúde coletiva. 1999; 4(2):315-29.

    11. Schraiber LB. O médico e seu trabalho: limites da liberdade. São Paulo: Hucitec; 1993.

    12. Schraiber LB. O médico e suas interações: a crise dos vínculos de confiança. 4a ed. São Paulo: Hucitec; 2008.

    13. Ferla AA. Clínica em movimento: cartografia do cuidado em saúde. Caxias do Sul: Educs; 2007.
    -1514. Gonçalves RBM. Medicina e História: raízes sociais do trabalho médico [dissertação]. São Paulo: Departamento de Medicina Preventiva, Universidade de São Paulo; 1979.;

  • the expansion of the offer of undergraduate medical courses signalled a possible future situation of market pressure, which would tend to reduce the levels of remuneration of the category22. Machado MH, organizadora. Os médicos no Brasil: um retrato da realidade. [livro eletrônico] Rio de Janeiro: Fiocruz; 1997..

Besides the aforementioned, other transformations could be identified in relation to the social factors that mediate the development of medical work in our society. Given this context, we consider fundamental to understand the ways in which changes in the political constitution of the medical corporation are taking place. In this sense, we developed a doctoral research, carried out along the research on Micropolitics of Work and Health Care, in the Graduate Program in Clinical Medicine of the Federal University of Rio de Janeiro, under a Doctorate Scholarship of CAPES. This study is also linked to a series of research on the genealogy and effects of the More Doctors Program, linked to the Observatory of Health Care Policies and Care, with CNPq funding support.

This paper is part of a larger set of studies, and its purpose is to analyze how the struggle of the entities of the medical category against one of the main policies of the Brazilian National Health System (SUS) has focused on the specifics of this profession: the More Doctors Program.

In July 2013, amid street protests across the country, the Brazilian government launched the More Doctors Program for Brazil. Its most visible face was the rapid provision of Brazilian and foreign physicians in doctor-less primary care teams, linking them to a specialization course through scholarships. The priority was for poor, low population density or peripheral regions of large urban centers. The Program also seeks to increase the number of physicians in the country by expanding undergraduate and medical residency1615. Gonçalves RBM. Tecnologia e organização social das práticas de saúde: características tecnológicas de processo de trabalho na rede estadual de centros de saúde de São Paulo. São Paulo: Hucitec; Abrasco; 1994.

16. Oliveira FP, Vanni T, Pinto HA, Santos JTR, Figueiredo AM, Araújo SQ, et al. Mais Médicos: um programa brasileiro em uma perspectiva internacional. Interface (Botucatu) [Internet]. 2015 Set [citado 2016 Abr 28]; 19(54):623-34. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-32832015000300623&lng=pt. http://dx.doi.org/10.1590/1807-57622014.1142.
http://www.scielo.br/scielo.php?script=s...
-1817. Cyrino EG, Pinto HA, Oliveira FP, Figueiredo AM. O Programa Mais Médicos e a formação no e para o SUS: por que a mudança?. Es Anna Nery [Internet]. 2015 Mar [citado 2016 Abr 28]; 19(1): 5-6. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-81452015000100005&lng=pt. http://dx.doi.org/10.5935/1414-8145.20150001.
http://www.scielo.br/scielo.php?script=s...
.

The initial number of Brazilians and foreigners who spontaneously joined the Program was much lower than necessary, with the vast majority of participants being Cuban doctors, who came through a cooperation agreement signed by the Brazilian Ministry of Health with the Organization Pan American Health Organization (PAHO), and with the Ministry of Public Health of Cuba1615. Gonçalves RBM. Tecnologia e organização social das práticas de saúde: características tecnológicas de processo de trabalho na rede estadual de centros de saúde de São Paulo. São Paulo: Hucitec; Abrasco; 1994..

The More Doctors Program suffered great resistance from Brazilian medical institutions, trying to make it unfeasible in the political, legal and public spheres1918. Federal nº 12.871, de 22 de outubro de 2013. Institui o Programa Mais Médicos, altera as Leis nº 8.745, de 9 de dezembro de 1993, e nº 6.932, de 7 de julho de 1981, e dá outras providências. Diário Oficial da União. 23 Out 2013.. As such resistance movements have not been sufficiently studied, we consider it relevant to try to understand how this struggle of the entities took place, even because it may be an analyzer, capable of contributing to the understanding of the way in which the political action of the medical category in Brazil has been constituted. As already stated by Gastão Campos, analyzing the changes occurring in the medical movement in the late 1970s and early 1980s, amid the great deeds of the professional group, "these moments of intense mobilization, when tempers are exacerbated when the will of struggle is put to the test at every moment, the analysis of the positions and the politics of the category in movement can be rich; everything that is accessory or secondary tends to be abandoned”33. Campos GWS. Os médicos e a política de saúde. São Paulo: Hucitec; 1988. (p. 37).

We focus on the identification of aspects directly related to the entities' actions: the agendas triggered, the political articulations carried out, the mobilizations carried out, the counter-offensive actions, etc. In this way, we try to inventory, categorize by themes and analyze the way in which the political struggles of the entities around the More Doctors were made.

Materials and methods

We chose to analyze the performance of national medical entities, traditional formal organizations representing the category. In order to do so, among other authors, the contributions of:

  1. Campos, whose research addressed "the practice of physicians while performed through their professional category as a movement of the corporation”33. Campos GWS. Os médicos e a política de saúde. São Paulo: Hucitec; 1988. (p. 22-23);

  2. the notion of collective subject, as formulated by Eder Sader, as a "collective where an identity is elaborated and organized by means of which its members intend to defend their interests and express their wills, constituting themselves in these struggles”2019. Santos LMP, Costa AM, Girardi SN. Programa Mais Médicos: uma ação efetiva para reduzir iniquidades em saúde. Ciênc Saúde Colet [Internet]. 2015 Nov [citado 2016 Abr 28]; 20(11): 3547-52. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232015001103547&lng=pt. http://dx.doi.org/10.1590/1413-812320152011.07252015.
    http://www.scielo.br/scielo.php?script=s...
    (p. 55);

  3. we used as well some conceptions of Maria da Glória Gohn, in her studies on social movements and their new configurations2120. Sader E. Quando novos personagens entraram em cena: experiências, falas e lutas dos trabalhadores da grande São Paulo, 1970-80. Rio de Janeiro:Paz e Terra; 1988., 2221. Gohn MG. Teoria dos movimentos sociais: paradigmas clássicos e contemporâneos. 3a ed. São Paulo: Edições Loyola; 2002.. Adding to these propositions, we aimed to research how the medical movement acted politically, developing social struggles that would place demands, and how it would carry out collective actions aiming at impacting the construction of relevant cultural processes in the dynamics of the social actors of the health sector.

However, we noticed that research with such emphasis was scarce in health academic production. Evidence of this: On March 10, 2015, we conducted a search on the Virtual Health Library - Bireme portal using the terms "doctors" and "politics" in the integrated search method, which were searched in all fields of the texts indexed in that database. 24441 references were found. Next, we used the following filters, related to the main subjects of the texts initially selected: Doctors, Politics, Medical Societies, Policy Formulation or Brazilian National Health System; It was expected that publications having any of these terms would be identified. We also specified those who had Brazil as the subject country or region and may have been published in any language. 103 references appeared, being fifty articles, 29 monographs, 23 theses and one characterized as "unconventional". When analyzing the summaries of these available materials, we identified that few were those that referred to aspects oriented to a political view of the medical category or its entities. And those who did, were either studies done more than twenty years ago, or more recent but that returned to the specifics of the professional performance in the first decades of the early twentieth century, in a more historical fashion.

Faced with this difficulty related to the low amount of research available to support the discussion and comparison of the results, we decided to develop a research of a qualitative, exploratory and analytical nature2322. Gohn MG. Novas teorias dos movimentos sociais. 5a ed. São Paulo: Edições Loyola; 2014. Among the more relevant associations selected following the objective of this study: the Federal Medical Council (Conselho Federal de Medicina-CFM), the Brazilian Medical Association (Associação Médica Brasileira -AMB) and the National Medical Federation (Federação Nacional dos Médicos -FENAM).

Regarding the temporal scope to be considered in the research, since there were no previous studies that could contribute with validated external criteria in order to better specify the temporal boundaries of the analysis, the search for sources considered as a starting point the month of January 2011, the beginning of a new administration of the federal government, the National Congress and state governments and parliaments, which are important interlocutors in the construction of the political disputes of the category. However, numerous references in the materials analyzed, indicated that the organization of the XII National Meeting of Medical Entities (ENEM) in July 2010 and the National Mobilization for the Appreciation of Doctors and Healthcare in Brazil, in October 2010. In this sense, we took as the starting point of the analysis the month of May 2010, showing the articulations for these events, allowing a broader understanding of the entities' struggles. And as the final moment of the analysis, we defined the month of December 2014, as it characterized the closure of the cycle of elected governments in 2010 and 18 months after the Program More Doctors launching.

The pre-defined sources were intended to cover the most varied forms that the leaders of the national medical entities used to make explicit their positions, actions and articulations in their political action. Therefore, we analyzed:

  • a book commemorating the 60th anniversary of the AMB, published in 2011;

  • videos with interviews of leaders of national medical entities on national television programs, especially the Presidents of CFM and AMB;

  • institutional videos of the entities made available on Youtube;

  • notes and Manifests issued by entities;

  • a book commemorating the forty years of FENAM, published in 2014;

  • the interventions of the Presidents of AMB, FENAM and CFM's 1st Vice-President, at the 259th Extraordinary Session of the Chamber of Deputies, held on September 4, 2013 to analyze the More Doctors Program;

  • two petitions and the opinions of the Attorney General's Office regarding proposals for Direct Action of Unconstitutionality (ADI) of the More Doctors Program to the Federal Supreme Court (STF);

  • videos with the full intervention of the Presidents of the Brazilian Association of Medical Education, FENAM, CFM and AMB, as well as AMB's 1st Treasurer, at the public hearing on the More Doctors Program, held at the Federal Supreme Court on November, 25th and 26th, 2013.

In addition to these materials, we analyzed the newspapers of the entities disclosed between the months of May 2010 and December 2014. Among them, Jornal Medicina, of CFM, monthly sent to all physicians who work in Brazil; The Journal of the Brazilian Medical Association (JAMB) is a bimonthly publication received by the doctors associated with AMB; The FENAM in the period, issued a magazine and a newspaper with irregular periodicity and few numbers. There were 56 editions of Jornal Medicina, 28 editions of JAMB and ten copies published by FENAM.

During the first half of 2015, all these sources were analyzed together. In relation to the newspapers for each edition, observing the highlights of the cover and reading in full all published articles. The subjects identified as related to the political aspects of the medical entities' performance were read in depth, reports that contained the main aspects addressed in their contents were made, besides pointing out elements related to this context. These records were initially aggregated in chronological order of the events to which they referred. Subsequently, all the material was systematized though inductively elaborated categories, according to the political aspects of the performance of the medical entities, which were elucidated before the analysis developed2423. Gil AC. Métodos e técnicas de pesquisa social. 5a ed. São Paulo: Atlas; 1999., 2524. Gil AC. Como elaborar projetos de pesquisa. 4a ed. São Paulo: Atlas; 2002..

We also searched the Folha de São Paulo newspaper's website, a daily publication whose print version has the largest national circulation, using the term "Mais Médicos" and filtering the papers in the "opinion" section. We identified eight articles by members of the entities, published until December 2014, which were also analyzed.

Comparing all these materials, we identified that a priority source for the elucidation of the political struggle of the entities was their newspapers, especially the CFM and the AMB. This is because we identify that the analysis carried out by the entities in these publications was consistent with what they defended in other dissemination media and with what they have expressed in the public spaces of debate and political dispute.

In order to identify relevant aspects of the political context related to the More Doctors Program not published in these sources, we proceeded to systematically read three national circulation publications that deal with politics, economy and society as a whole, published between the months of June 2013 and December 2014: Carta Capital Magazine, weekly publication, and the monthly magazines Caros Amigos and Le Monde Diplomatique Brasil. In this analysis, we could identify how other political actors in society in addition to the entities, participated in this dispute.

With such methodological strategies, we have shown how the physicians' political agenda was constituted and how their claims developed in their struggles during the period in question.

Results and Discussion

Initially, we must emphasize that in the three years prior to the launch of More Doctors, a period of time that covers the analysis carried out in this research, the Brazilian medical entities performed intense joint action, around a common and complex common agenda, in which they managed to integrate Interests of the category for the public and private sectors. In these years, the entities triggered actions characterized by:

  1. development of several regulatory measures on the performance of the medical category itself as a relevant part of the political action of the entities;

  2. intense vertical and horizontal integration between entities, allowing various organizations to leverage their resources for common purposes;

  3. important role of articulating bodies that operated in the integrated struggles and agendas, especially the Political Affairs Committee, the National Commission of Supplementary Health and the National Commission for the SUS, which also assumed the role of broadening the articulation with the parliamentarians and institutions of the State and civil society, aiming to add support to the struggles of the category. Explanation of all these measures, however, goes beyond the limits of this text. To those interested in this aspect, we suggest accessing the thesis that resulted in this paper2625. Eco U. Como se faz uma tese. 17a ed. São Paulo: Perspectiva; 2001..

We suggest that this period of time may be characterized as a time of consensus-building by the hegemonic forces of the medical class, operating from the inside of the entities, allowing us to analyze the medical group as a corporative body (not withstanding particular divergent movements) when observed through the medical entities lens. From this point of view, the period June-October 2013 was dominated by the resistance to the More Doctors Program and marked not the emergence, but the moment when the unified mobilizations of the medical entities reached their apogee within the period studied in this research.

We need to acknowledge that the dispute over core issues related to the Program preceded its launch. Medical entities have long been involved in actions against the revalidation of medical diplomas issued abroad, against the increase of medical graduation courses, in defense of a national public career for physicians working in the SUS, among others themes. However, the struggle against the More Doctors Program enabled these and other agendas to be unified, at a time when the whole Brazilian society was experiencing intense social mobilizations2726. Gomes LB. A atual configuração política dos médicos brasileiros: uma análise da atuação das entidades médicas nacionais e do movimento médico que operou por fora delas. Rio de Janeiro [tese]. Rio de Janeiro: Faculdade de Medicina, Universidade Federal do Rio de Janeiro; 2016.. The following are the entities' positions regarding the Program, which was created through a normative act of the Brazilian Government, in the form of the Provisional Measure nº 621 of 2013 (MP 621/13).

According to the AMB, MP 621/13 tried to implement the "Medicine of the Poor". At the same time, the entity states that "it is more than proven that the performance of the majority of doctors trained abroad does not correspond to the needs of the Brazilian market, because they present a highly deficient training"2827. Maricato E, Harvey D, Rolnik R, Braga R, David M, Vainer C, et al. Cidades Rebeldes: Passe Livre e as manifestações que tomaram as ruas do Brasil. São Paulo: Boitempo: Carta Maior; 2013. (May-June 2013, p. 16)c c As we have analyzed dozens of numbers from the journals Medicine and JAMB, the references at the end of the paper indicate only the month of the first and last volume consulted. However, in order to allow accurate identification of the source, when literal quotes from excerpts of these publications occur, in addition to the numerical reference, the month and year of publication in brackets. , especially criticizing the medical training of Cuba and Bolivia.

In the view of CFM, "there has never been such a violent aggression against the category and against the assistance offered to the population"2928. Jornal da Associação Médica Brasileira. São Paulo: Associação Médica Brasileira; maio/jun 2010 - nov/dez 2014. (June 2013, p. 3).

The National Academy of Medicine (ANM) and the Brazilian Federation of Medical Academies (FBAM) characterized the Brazilian government as authoritarian and criticized MP 621/13 and the vetoes to the Law of the Medical Act, as it became known the bill proposing the regulation of the medical profession99. Merhy EE. Em busca do tempo perdido: a micropolítica do trabalho vivo em saúde. In: Merhy EE, Onocko R; organizadores. Agir em saúde: um desafio para o público. 2a ed. São Paulo: Hucitec; 2002. p. 71-112..

Also, many of the medical schools reacted to MP 621/13, either to its content or to the way in which its contents were defined, and the Brazilian Association of Medical Education2928. Jornal da Associação Médica Brasileira. São Paulo: Associação Médica Brasileira; maio/jun 2010 - nov/dez 2014. expressed a position contrary to MP 621/13.

In a jointly signed text, AMB, FENAM, CFM, FBAM and the National Resident Physicians Association (ANMR) considered that MP 621/13 proposed to create medicine for the rich and another for the poor, as well as posing a serious health risk for the population and worsening medical training2928. Jornal da Associação Médica Brasileira. São Paulo: Associação Médica Brasileira; maio/jun 2010 - nov/dez 2014..

We consider that the central motive of this reaction was the attempt of the government to interfere in the self-regulation of the medical category, with potential impact on the definition of the medical labor market. Among the actions triggered, the authorities created a National Mobilization Committee, which systematically published notes and materials directed for the class and society as a whole. They resigned from the technical chambers and government commissions in which they participated and developed intense action with the legislature, in order to prevent the approval of the law that would regulate the Program, holding meetings with parliamentarians and public acts in the National Congress. They released documents and booklets in which they claimed More Doctors to be unconstitutional, in addition to having issued in July 2013 an edition of Jornal Mobilização Médica, an integrated publication of the entities, sent to all doctors in the country.

They also held several meetings with hundreds of leaders of the medical entities, during the months that followed the launch of the Program, highlighting an Extraordinary National Meeting of Medical Entities, held from August 08 to 10, 2013. In these moments, besides analyzing the political conjuncture, the entities coordinated actions throughout the national territory. On July 3, 2013, the first protests occurred at state levels against the arrival of foreign professionals by More Doctors. That same month, there were further protests and public demonstrations by doctors in various regions of the country, on July 16, 23, 30 and 31, against MP 621/13 and vetoes to the Law of Medical Act2928. Jornal da Associação Médica Brasileira. São Paulo: Associação Médica Brasileira; maio/jun 2010 - nov/dez 2014..

Nevertheless, in August 2013, the National Congress maintained the vetoes of the President to the Law of the Medical Act and in October of 2013, the Chamber of Deputies and the Federal Senate2827. Maricato E, Harvey D, Rolnik R, Braga R, David M, Vainer C, et al. Cidades Rebeldes: Passe Livre e as manifestações que tomaram as ruas do Brasil. São Paulo: Boitempo: Carta Maior; 2013.,2928. Jornal da Associação Médica Brasileira. São Paulo: Associação Médica Brasileira; maio/jun 2010 - nov/dez 2014., passed MP 621/13.

In addition to the dispute against the federal government and the attempt to convince parliamentarians and the population about the inadequacy of the More Doctors Program, we identified three other relevant strategies developed by medical entities: questioning the actions of Cuban doctors in the country; the judicialization of the dispute; and the attempt to wear off the Program in its implementation. We will summarize these aspects below.

Strategies against the More Doctors Program

Criticism of Brazilian medical entities for the performance of Cuban physicians precedes More Doctors, and it has been elaborated, especially, regarding the missions of these professionals in Venezuela and Bolivia, as well as an earlier experience of Cubans in the Brazilian state of Tocantins2928. Jornal da Associação Médica Brasileira. São Paulo: Associação Médica Brasileira; maio/jun 2010 - nov/dez 2014.. It was stated that "Cuban doctors proved to be unprepared to serve populations with a more complex and different health risk profile than they were accustomed to dealing with on the Caribbean island”2827. Maricato E, Harvey D, Rolnik R, Braga R, David M, Vainer C, et al. Cidades Rebeldes: Passe Livre e as manifestações que tomaram as ruas do Brasil. São Paulo: Boitempo: Carta Maior; 2013. (Sep-Oct 2013, p. 15).

It was also stated that among the main motivators of this Program would be the political interests between the governments of Brazil and Cuba, to reinforce the coffers of the Cuban government2827. Maricato E, Harvey D, Rolnik R, Braga R, David M, Vainer C, et al. Cidades Rebeldes: Passe Livre e as manifestações que tomaram as ruas do Brasil. São Paulo: Boitempo: Carta Maior; 2013..

It was emphasized that Cuban doctors would have curtailed basic rights of coming and going and having free relationships, since they would be prohibited from marrying Brazilians or getting pregnant during their stay in the country. Also, they would suffer coercion from members of the Cuban government that exerted the management of the Program in Brazil, and may have their passport withheld by the Cuban authorities. This would characterize, according to the entities, a semi-slavery regime, a condition not allowed by the Brazilian constitution. While the CFM stated that "it is necessary to be aware that coercive or limiting measures practiced in authoritarian or dictatorial regimes do not reproduce in the municipalities of the interior or in the outskirts of the big cities"2928. Jornal da Associação Médica Brasileira. São Paulo: Associação Médica Brasileira; maio/jun 2010 - nov/dez 2014. (Aug 2013, p. 3). Although with other tones, criticisms of established labor relations and the curtailment of rights of Cuban professionals who worked in More Doctors also came from leaders of the health movement3029. Jornal Medicina. Brasília: Conselho Federal de Medicina; maio 2010 – dez 2014..

Using such positions, medical entities tried to delegitimize the actions of Cuban doctors in the face of the population, as well as to instigate identity and corporate defense actions among Brazilian doctors. However, these strategies seem to have found a limit to the wear and tear of the entities, because they were related to acts classified as xenophobia by some physicians, which were transmitted in the media, blogs and social networks.

Faced with this facts the entities changed the emphasis of criticism: on the one hand, by emphasizing that their position would not be xenophobic or contrary to the arrival of foreign physicians to work in Brazil, as long as they revalidated their diplomas; on the other, they started to defend that the Brazilian government guarantee to the Cubans the same rights and benefits of the other participants of the Program.

In that sense, they stated that PAHO would be acting as an intermediary/exploiter, a situation that CFM reported to the World Health Organization and the International Labor Organization. This characterization of PAHO's activities was the subject of a response from the Brazilian government authorities, who valued the contribution of this international organization to all American countries. This position of entities also did not have the desired effect2827. Maricato E, Harvey D, Rolnik R, Braga R, David M, Vainer C, et al. Cidades Rebeldes: Passe Livre e as manifestações que tomaram as ruas do Brasil. São Paulo: Boitempo: Carta Maior; 2013.,2928. Jornal da Associação Médica Brasileira. São Paulo: Associação Médica Brasileira; maio/jun 2010 - nov/dez 2014..

Faced with the defeats suffered by the medical entities, several actions were triggered in an attempt to judicialize the policy, aiming to hamper the operation and erode the image of the More Doctors Program. Also, they sought to limit the scope of action of foreign physicians linked to the Program2928. Jornal da Associação Médica Brasileira. São Paulo: Associação Médica Brasileira; maio/jun 2010 - nov/dez 2014..

But the measures triggered in that context allow affirming that the main intention of the entities was to be able to establish through judicial means the illegality of the Program. In this sense, two strategies were highlighted: first, to trigger and support measures of the Federal General Attorney and the Public Prosecutor's Office, arguing that they sought to protect the population from illegal medical practice by professionals who did not revalidate their diplomas2928. Jornal da Associação Médica Brasileira. São Paulo: Associação Médica Brasileira; maio/jun 2010 - nov/dez 2014.; second, by entering two proposals for Direct Action of Unconstitutionality (ADI), filed in the Federal Supreme Court in August 20133130. Campos GWS. Mais médicos e a construção de uma política de pessoal para a Atenção Básica no Sistema Único de Saúde (SUS). Interface (Botucatu) [Internet]. 2015 Set [citado 2016 Abr 28];19(54):641-2. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-32832015000300641&lng=pt. http://dx.doi.org/10.1590/1807-57622015.0286.
http://www.scielo.br/scielo.php?script=s...
, 3231. Advocacia Geral da União (BR). Petição Ação Direta de Inconstitucionalidade No. 5035. Brasília. 19 Ago 2013.. Although these measures generated debates and public hearings about the Program, until the closing of this research they had not been able to interrupt the More Doctors Program.

The medical entities however, pointed out their defeats in this process as the result of an intense marketing campaign by the Brazilian government, aimed at eroding the image of these professionals. Given this fact they reinforced the mobilization of the category as a whole, seeking to recover their image before the patients. To do so, the solution found was to strengthen the dialogue with the population, in order to regain the symbolic value of physicians in society. In addition, the direct conversation with the users would aim at undermining the government's proposals and even convincing them of the need to change the federal government in the electoral process that occurred in late 20142827. Maricato E, Harvey D, Rolnik R, Braga R, David M, Vainer C, et al. Cidades Rebeldes: Passe Livre e as manifestações que tomaram as ruas do Brasil. São Paulo: Boitempo: Carta Maior; 2013.,2928. Jornal da Associação Médica Brasileira. São Paulo: Associação Médica Brasileira; maio/jun 2010 - nov/dez 2014..

Faced with the impossibility of impeding the performance of the foreign doctors linked to the More Doctors Program, the entities developed three new modalities of dispute regarding the Program, in order to undermine it. In the first of these, they used their ability to regulate the actions of the doctors over whom they have direct interference, and in this sense, Brazilian physicians involved in the management of the Program or in the supervision of foreign doctors were threatened or coerced2827. Maricato E, Harvey D, Rolnik R, Braga R, David M, Vainer C, et al. Cidades Rebeldes: Passe Livre e as manifestações que tomaram as ruas do Brasil. São Paulo: Boitempo: Carta Maior; 2013.,2928. Jornal da Associação Médica Brasileira. São Paulo: Associação Médica Brasileira; maio/jun 2010 - nov/dez 2014.. To do so, among other arguments, they were based on Article 49 of the Brazilian Medical Code of Ethics, which prohibits physicians "to act in contrary to legitimate movements of the medical category for the purpose of obtaining advantages"3332. Advocacia Geral da União (BR). Petição Ação Direta de Inconstitucionalidade No. 5037. Brasília. 26 Ago 2013. (p. 91).

The second strategy materialized in the complaints that the More Doctors was being run in contrary to what was established in its own legislation. Therefore, since it was not possible to overturn the regulations, it was demanded its full compliance using all clauses intended to identify situations in which it could intervene to paralyze its activities due to not guaranteeing the required conditions. In order to develop such measures, in addition to the direct monitoring carried out by the entities, there was also broad visibility to press reports that showed errors and problems of More Doctors2827. Maricato E, Harvey D, Rolnik R, Braga R, David M, Vainer C, et al. Cidades Rebeldes: Passe Livre e as manifestações que tomaram as ruas do Brasil. São Paulo: Boitempo: Carta Maior; 2013.,2928. Jornal da Associação Médica Brasileira. São Paulo: Associação Médica Brasileira; maio/jun 2010 - nov/dez 2014.. Still, this second line of action had a different face, present in the AMB's allegation that the Ministry of Health was manipulating data in order to affirm that there was expansion of access and improvement of health conditions thanks to More Doctors. In other words, besides giving visibility to the existing problems, it put in suspicion the positive image that the government tried to pass on the success of the Program2827. Maricato E, Harvey D, Rolnik R, Braga R, David M, Vainer C, et al. Cidades Rebeldes: Passe Livre e as manifestações que tomaram as ruas do Brasil. São Paulo: Boitempo: Carta Maior; 2013..

The third strategy sought to point out that several professionals would have given up More Doctors since its first days of service2827. Maricato E, Harvey D, Rolnik R, Braga R, David M, Vainer C, et al. Cidades Rebeldes: Passe Livre e as manifestações que tomaram as ruas do Brasil. São Paulo: Boitempo: Carta Maior; 2013.. This measure, however, only had some provisional effect when the first Cuban doctors linked to the Program effectively defected. This was done in a case that was extremely exploited in the media - not only by the medical entities, but also by the forces of opposition to the federal government -, i.e. the desertion of Doctor Ramona Rodriguez, on February 4, 20142827. Maricato E, Harvey D, Rolnik R, Braga R, David M, Vainer C, et al. Cidades Rebeldes: Passe Livre e as manifestações que tomaram as ruas do Brasil. São Paulo: Boitempo: Carta Maior; 2013.,2928. Jornal da Associação Médica Brasileira. São Paulo: Associação Médica Brasileira; maio/jun 2010 - nov/dez 2014..

These strategies described above, while pointing out inflections in the ways of their development, prolonged the fight against the More Doctors Program until the end of the period analyzed in this research. The entities seem to have identified that, since they were not able to prevent the activity of foreign doctors in Brazil - the main focus of the tensions in the months after June 2013- it would be necessary to shift their attention to other axes of the More Doctors Program. This may have been due, in part, to the legitimacy that over time, the presence of foreign doctors was gaining, within the population living in the regions directly benefited by the Program1918. Federal nº 12.871, de 22 de outubro de 2013. Institui o Programa Mais Médicos, altera as Leis nº 8.745, de 9 de dezembro de 1993, e nº 6.932, de 7 de julho de 1981, e dá outras providências. Diário Oficial da União. 23 Out 2013.. This approval was also considered the main motivation for a resumption of the positive evaluation of President Dilma Rousseff, after the bad public opinion regarding the government members in the demonstrations that followed June of 2013. So the Brazilian government itself began to consider the Program as one of the most relevant measures of President Dilma, and further intensify the campaigns in defense of its implementation3433. Conselho Federal de Medicina (BR). Resolução CFM Nº 1.931, de 17 de setembro de 2009. Diário Oficial da União. 24 Set. 2009; Seç I: 90-2. 13 Out. 2009. Seç I: 173 (retificação em vigor a partir de 13 Abr 2010)..

Faced with the failure of attempts to prevent the work of foreign doctors, especially Cubans, who represented the vast majority of these, the entities began to focus more attention on criticisms of the other axes of the More Doctors Program, especially those focused on the expansion of Medical schools and graduate vacancies, as well as medical residences. Therefore they:

  1. carried out various activities to discuss the situation of medical education;

  2. criticized the public selection of municipalities with the intention of opening new medical courses;

  3. refused to participate in the process of revision of the national curricular guidelines of the undergraduate courses, rejecting its new version, which indicated the need for modification of the Internship period and intensification of the teaching in Primary care;

  4. expressed opinions against the expansion of medical residency vacancies, stating that adequate planning would not be available and the necessary investment in infrastructure and preceptorship would not occur, leading to the loss of quality and, consequently, the legitimacy of the training of specialists2827. Maricato E, Harvey D, Rolnik R, Braga R, David M, Vainer C, et al. Cidades Rebeldes: Passe Livre e as manifestações que tomaram as ruas do Brasil. São Paulo: Boitempo: Carta Maior; 2013., 2928. Jornal da Associação Médica Brasileira. São Paulo: Associação Médica Brasileira; maio/jun 2010 - nov/dez 2014..

We found measures such as these continuing to be launched until December 2014. However, the articulated performance of medical entities, consistently built in the years 2010 to 2013, was seriously shaken as a result of divergences between AMB and CFM in the vote on MP 621 / 13 in the Chamber of Deputies, held in October 20132928. Jornal da Associação Médica Brasileira. São Paulo: Associação Médica Brasileira; maio/jun 2010 - nov/dez 2014.. Thus, despite the fact that some of the actions were jointly pursued for some time, the tendency was for the relations between the leaders of the national medical entities to be intensely eroded, causing, among other effects a significant loss in the capacity to perform large national-scale collective action events. This tension in their relationship had not been reversed until the end of 2014, when the period of analysis of this research ended. In this context, there was evidence of a loss of unified fighting capacity at that time, despite the scenario of the actors remaining open for new power games.

Final Considerations

When analyzing the more general line of action of the national medical entities in the period studied, it is possible to affirm that, to a great extent we have identified the construction of theoretical formulations, the production of agendas for struggles and the triggering of effective actions that may become what Gastão Campos had outlined as being the constructions of the political current of the neo-liberals33. Campos GWS. Os médicos e a política de saúde. São Paulo: Hucitec; 1988.,66. Campos GWS. A saúde pública e a defesa da vida. São Paulo: Hucitec; 1991.. According to Campos, this movement had assumed the prevailing strength of the medical movement, trying not only to represent the various fractions of the category, but also to unify the performance of its entities around corporate interests. We believe that this perspective was strengthened even more in the medical entities in the period analyzed in this research. In addition, we believe that it is possible to affirm that, rather than merely a continuation of the form of action of neoliberal movements in health, as we have shown, there is a deepening, if not an effective renewal, in the way of making politics on the part of the medical movement that acted with the entities during the period under study.

Also, we have been able to identify that an intense fight of medical entities has developed against the More Doctors Program involving extremely diverse strategies throughout the national territory. However, their failure to halt the Program has led to significant changes in their actions in relation to the focus of the disputes during the process.

These disputes produced a significant political mobilization of the medical category in the second half of 2013. Meanwhile, the relations between the leaders of the entities were in crisis due to the differences in the positions of CFM and AMB around the voting negotiations of MP 621 / 2013. This tension among entities would remain until the end of 2014, without it being clear whether and how it would be possible to resume a unified performance of these organizations in the short and mid term.

Finally, we identified that the medical movement demonstrated a great ability to act, mediating in most of the time the defense of diverse interests and strengthening its identity construction as a collective subject2019. Santos LMP, Costa AM, Girardi SN. Programa Mais Médicos: uma ação efetiva para reduzir iniquidades em saúde. Ciênc Saúde Colet [Internet]. 2015 Nov [citado 2016 Abr 28]; 20(11): 3547-52. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232015001103547&lng=pt. http://dx.doi.org/10.1590/1413-812320152011.07252015.
http://www.scielo.br/scielo.php?script=s...

20. Sader E. Quando novos personagens entraram em cena: experiências, falas e lutas dos trabalhadores da grande São Paulo, 1970-80. Rio de Janeiro:Paz e Terra; 1988.
-2221. Gohn MG. Teoria dos movimentos sociais: paradigmas clássicos e contemporâneos. 3a ed. São Paulo: Edições Loyola; 2002., and can be characterized as one of the most recent examples of a dynamic and powerful movements of a professional category in Brazil.

Within the limits already indicated in this research, we consider that another genealogical study of the medical movement, with temporal scope and intentionalities different from those developed here, could better identify the connections and displacements that exist between the forms of political struggle of this category in a expanded timeline.

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  • c
    As we have analyzed dozens of numbers from the journals Medicine and JAMB, the references at the end of the paper indicate only the month of the first and last volume consulted. However, in order to allow accurate identification of the source, when literal quotes from excerpts of these publications occur, in addition to the numerical reference, the month and year of publication in brackets.

Publication Dates

  • Publication in this collection
    20 July 2017
  • Date of issue
    2017

History

  • Received
    04 May 2016
  • Accepted
    06 Dec 2016
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