Deficit in the Amazon remains even with More Doctors – 05/21/2023 – Health

The Legal Amazon, the region most lacking in public sector physicians in the country, will continue to have a shortage of professionals even with the almost 1,900 hirings foreseen in the public notice of the new More Doctors, relaunched by the Lula government this year.

Even if all vacancies are filled, the region will reach at most the level of SUS doctors (Sistema Único de Saúde) that the rest of Brazil registered 15 years ago, considering the proportional rate per inhabitant.

• Resumption of Mais Médicos prioritizes the Amazon, with 1,869 vacancies (one third of the total)

• Even with the contribution, the poorest region faces a delay of 15 years in relation to the rest of the country

• Disparity is increasing; only exception was in the first phase of the program, in 2013

• Supply of professionals almost doubled in the country, but policies fail in regional distribution

The disparity between the Amazon and other regions has historically increased. It only decreased during the first phase of Mais Médicos, promoted by then-president Dilma Rousseff (PT) in 2013. In the following years, with the dehydration of the program, the difference increased again.

To equalize the region proportionally, an additional 21,000 professionals would be needed in the Amazon, regardless of the source of hiring — not only through Mais Médicos, but also through broader public policies.

The analysis of Sheet it is based on data from the CNES (National Register of Health Establishments) and covers only the universe of professionals working in the SUS.

The Legal Amazon (Northern states, Mato Grosso and part of Maranhão) registers many of the worst health indicators in the country. It is also home to most of the indigenous population, which depends on medical assistance in remote and difficult-to-reach areas. The sector was directly impacted by the departure of Cuban doctors during the Jair Bolsonaro (PL) government.

With the new More Doctors, the region can gain an addition of up to a thousand vacancies, in addition to the 869 replacement provided for in the public notice. The total of 1,869 represents almost a third of the jobs announced at this stage for the whole country (6,252) and is equivalent to the number destined for the Southeast (1,848), which has triple the population.

In the cities that make up the Legal Amazon, the current rate of physicians per thousand inhabitants (1.02) is comparable to that registered in the rest of Brazil in February 2008. Outside the region, the general index rose from 1.01 to 1.76 in the last 15 years.

In a maximum projection –if all vacancies in the new Mais Médicos were filled–, the offer would go from the current 29,084 professionals (1.02 per thousand inhabitants) to a total of 30,953 in the Amazon (1.09). In this scenario, the region would see a 6.4% increase in the rate.

In the rest of the country, the impact would be 1.3%, from the current 325,038 professionals (1.76 per thousand inhabitants) to 329,42 doctors working in the public network (1.78).

Data show that public policies in recent years have failed to narrow the disparity. For this, the increase in supply in the Amazon should happen at a much higher pace than in the rest of the country, contrary to what has been happening.

The only period with an inversion in this movement coincides with the interval between the launch of the Mais Médicos program, in July 2013, and the end of PT management in 2016.

In March of this year, the program had 8,366 vacancies filled — less than half of the 18,240 reached in the first phase. Another 5,648 professionals worked in Médicos Pelo Brasil, a program announced as a replacement for Mais Médicos in the Bolsonaro administration.

Now, the federal government says that the intention is to reach a total of 28 thousand professionals by the end of the year. There will be another 10,000 vacancies offered in exchange for the municipalities and “presence mainly in areas of extreme poverty”, with scholarships and other benefits for work in peripheries and remote regions.

The priority is for Brazilian professionals. In case of unfilled vacancies, Brazilians trained abroad or foreign doctors may be called.

For Monica Andrade, coordinator of the Study Group on Health Economics and Crime and professor at UFMG (Federal University of Minas Gerais), there has been a significant improvement in the number of physicians in the country in recent years, largely thanks to incentive programs from the government in more vulnerable areas.

She considers, however, that this growth is perhaps still reflecting the inequalities that exist between the public and private systems.

“The growth rate of physicians in the country has increased five times faster than the population growth. While in the last four decades the population has increased by about 5% every five years, physicians have increased by 25% in the same period. The problem is that the growth does not keep up with the most needy areas”, he says.

In the period with official data available, between August 2007 and March this year, the total number of professionals working at the SUS practically doubled in the country (96.6%), going from 180,117 to 354,122. The increase is a direct reflection of the opening of undergraduate courses and openings in medicine.

As the Brazilian population also grew in the period, the rate of doctors rose 74.2% (from 0.95 to 1.66 per thousand inhabitants), considering those who work in the SUS.

“Of course, looking at the end of the 1980s, when we had a rate below one doctor per thousand inhabitants, the numbers improved, the growth was good. But now we need to adapt to reduce regional inequalities”, explains Andrade.

One point raised by her is the difficulty that the newly formed doctor finds in more distant areas, where he will probably be the only or one of the only health professionals responsible for an entire territory.

“The question of initiatives such as Mais Médicos is not only about opening new vacancies, but also training these doctors so that they are active in areas with deficits and have public policies to reduce inequalities”, he says.

Gabriela dos Santos Marques is a family and community physician, active in the Mais Médicos program in the municipality of São José, in Santa Catarina, and agrees with Andrade’s vision. She states, however, that the shortage of professionals occurs not only in municipalities in the North, but in these places, in general, the so-called social determinants of health are more acute.

“There are areas with a deficit of primary care throughout the country, but it is clear that in indigenous territories, in more remote regions, farther from the capitals, this concentration of doctors is even lower.”

The very calculation of the rate of physicians per population is contested, as it ignores that, in order to be effective, the family health strategy (ESF) needs a multidisciplinary team.

“We discussed in primary care a concept called the law of inverse care. In places where populations have better socioeconomic conditions, care is also better, the population rarely misses their scheduled examination, there are medicines and treatments available. And precisely in areas where it is the higher the demand for health, the depletion of resources occurs”, explains Marques.

In a booklet published at the launch of Mais Médicos in 2013, the government said that “the World Health Organization does not have a specific parameter” and that the program would use as a reference “the proportion found in the United Kingdom, because, after Brazil, it has the largest universal public health system guided by primary care.”

The most recent international indicator from the OECD (Organization for Economic Cooperation and Development) points out that the United Kingdom had a rate of 3.2 doctors per thousand inhabitants in 2021, while Brazil recorded 2.1, including professionals who also work in the private network.

“Today we have a total of about 15,000 doctors trained each year, but perhaps along with this growth, with the opening of courses at the university, strengthening and training has been neglected so that recent graduates work in more needy places”, ponders Andrade.

“There are many myths about the Mais Médicos program, and one of them is that the program only encourages the opening of vacancies according to the municipalities listed, and that’s not quite it. There is also a training counterpart for professionals to work with family medicine “, says Marks.