There are 11,255 family and community doctors in Brazil, 2.3% of the total
Initially implemented as the Family Health Program in 1994, nearly three decades later, the Family Health Strategy (ESF) has consolidated itself as the main gateway for populations into the Unified Health System (SUS). Given that the majority of our population relies exclusively on the unified system to access healthcare services, the proper functioning of the main gateway to the system is critical to their well-being.
One of the chronic difficulties the United States faces in organizing the ESF is sourcing and retaining physicians for family health teams.
As part of the team, the physician is expected to have the clinical capacity to resolve most of the population’s health conditions, especially the most common ones, without the need for referral to other specialists. It must also be able to recognize urgent cases, requiring immediate transfer to a hospital environment, as well as coordinating the care of people passing through other specialists and health services, as these people remain linked to the ESF, which should be the centre. Care coordinator.
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All of this includes care for the full range of gender, age and health conditions, taking into account people’s social and family relationships in the context of their care and building networks in the community they are in to better understand and act on it.
Practicing medicine at ESF is a challenge with multiple layers of complexity. The specialty that aims to train professionals ready for this role is Family and Community Medicine (MFC). Although recognized specialist residency programs have been in existence since the early 1980s, MFC specialists began training in larger numbers in Brazil just over ten years ago.
Demographic data The latest medical report shows that in 2022 there were 11,255 family and community doctors in Brazil (2.3% of the total number of doctors). This number represents a significant increase when compared to data for 2012, when there were only 3,353 such specialists in the country (1.2% of doctors that year), but it is still far fewer than necessary.
According to the Ministry of Health, there are currently more than 43,000 family health teams in the country. Just to meet the need for an MFC specialist for each team, we would need at least four times as many as the just over 11,000 professionals that currently exist. Given that some of these professionals work in managerial positions at SUS, in assistance areas other than the European Social Fund, and in private health, we actually have a scenario of an even greater shortage of these professionals.
Another way to think about these numbers is to compare them to other countries with public national health systems. Some examples of the ratio of MFC specialists compared to the total number of doctors in the country, according to OECD data: Australia 31%; Canada 47%; Spain 21%; France 30%; and the United Kingdom 25%. Although these countries have health systems with very different characteristics, they all share a much higher percentage of MFC among their physicians, compared to the current 2.3% of the Brazilian medical workforce trained in this specialty.
If there is a shortage of doctors, how can we train them?
But if there is a shortage of family and community doctors in the country, how can we train them? The strategy considered ideal, through medical residency programs, has proven insufficient. Just over a thousand doctors enter MFC residency in Brazil annually. At this rate of training, it would take about thirty years to train the number of specialists needed to fill all current ESF teams, regardless of what other positions these professionals also hold.
In addition to medical residency, the Ministry of Health has invested in the Mais Médicos programme, in its latest edition, as a complementary strategy to MFC training in Brazil. In its original proposal in 2013, the programme, together with other pre-existing policies such as Pró-residência, was able to bring about an increase in the number of medical residency vacancies overall and proportionately in strategic areas, including the MFC. On the other hand, in the 2023 proposal, Mais Médicos intends to use this provision as a strategy for training specialists.
In this scenario, doctors participating in the program have an initial period of four years of work at the ESF, which is the time needed to be able to take the MFC title examination, as well as the ability to be included in professional master’s programs during their participation. With the federal government forecasting that the number of doctors enrolled in the program will reach 28,000 by the end of 2023, we will soon have formed a significant portion of the MFC specialist medical workforce needed to cover the needs of the ESF.
The current proposal of Mais Médicos has the advantage of seeking an effective solution to the shortage of MFC specialists in the country, but there are some issues that need to be discussed.
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The first is the outcome for existing MFC housing. Insofar as it is proposed as a complementary strategy for training specialists, the current proposal, with much higher wages than residency grants and offerings such as professional master’s degrees associated with them, tends to empty medical residency vacancies, especially in programs in rural cities. It has historically had more difficulty attracting resident physicians.
Considering that what Mais Médicos offers are convenient extras to attract professionals, we can suggest extending these same attractions to MFC residency programs, so as not to empty them out.
The training of doctors participating in Mais Médicos is also a point of concern. In medical residency, the presence of a preceptor, a more experienced professional who guides learning and serves as a model for residents, is perhaps the most important factor in training these physicians.
As in Mais Médicos, due to its size and organisation, it is not possible to guarantee the presence of trainers as in medical residency coordination, it is necessary to ensure that the educational offerings and level of supervision of the participating doctors are adequate for the participating doctors. Training appropriate healthcare professionals at ESF.
Another issue to be discussed is the working relationship between Mais Médicos doctors. The current method of recruiting these professionals is through scholarships, funded by the federal government, without the need for an employment relationship.
This format becomes very attractive for municipal managers, who find in medical colleagues a solution to the financial constraints imposed by the Brazilian legal framework, such as the Fiscal Responsibility Law, which limits public spending on human resources in areas such as health and other austerity measures. Policies, such as the fiscal pillars recently discussed in the legislature.
On the other hand, we currently have a scenario in which Mais Médicos becomes the main strategy for providing doctors to ESF at the national level through the recruitment of scholarships. These professionals remain associated with the program for long periods, and municipalities have no possibility of offering more attractive employment relationships for the medical workforce.
And in the long term?
It is therefore imperative to discuss whether this path is sustainable in the long term. If not, what are our options as a public health system? Amending the legal framework inspired by fiscal austerity policies does not seem possible in the short term. Are we moving toward a model in which the federal government is responsible for providing doctors to Social Security over the long term? In this scenario, it would be appropriate to reconsider the method of recruiting Mais Médicos, because we do not consider the establishment of a scholarship category the main policy for the country’s medical workforce as appropriate.
We understand Mais Médicos as a government policy necessary to provide doctors in the country. For this requirement to be effective, it must be linked to the valorization of professionals with appropriate training (MFC specialists) to work on the family health strategy.
Strategies and paths for a long-term sustainable supply of doctors must be discussed between the federal government, states and municipalities, including social movements, unions and scientific societies in the region.
Daniel de Medeiros Gonzaga He is President of the Association of Family and Community Medicine of the State of Rio de Janeiro (AMFaC-RJ).
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Read other articles in the column O SUS no seu Cotidiano no Brasil de Fato MG
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This is an opinion article. The author’s vision does not necessarily reflect the editorial line of the newspaper.
Edited by: Ellis Almeida
