Missed goals for Brazilian healthcare
What does the future hold for medical students in Brazil?
In the lead up to Brazil hosting the 20th FIFA World Cup in June and the Olympics in 2016, there have been protests over the amounts of money spent on these projects rather than on public health and education. Brazil has the fifth highest population in the world and with it the fifth highest number of doctors: 387 013. There are 216 medical schools in Brazil, with more than 16 500 new doctors graduating every year; only India has more (222 medical schools). Research by the Brazilian Health Ministry shows that the number of doctors in Brazil grew by 530% between 1970 and 2011. Brazil’s constitution says that free healthcare must be available to all its citizens. It has a national health system, the Unified Health System or SUS, similar to the NHS in the United Kingdom as well as an expanding and prominent private healthcare sector. It would seem that everything is in place for a thriving and comprehensive healthcare system, but the figures hide some big problems.
The country has a doctor to patient ratio of 1.9 per 1000 people, which is above the World Health Organization’s recommendation of 1 per 1000 and that of other emerging economies such as India (0.7), China (1.4), and South Africa (0.7). However, it is still below that of the United Kingdom (2.8) and the United States (2.5). The government aims to reach 2.7 doctors per 1000 patients, and to achieve this Brazil is looking to recruit an extra 168 000 doctors.
Although the number of doctors graduating increased by 69% between 2000 and 2011, there is an imbalance in the workforce and the specialties medical students decide to work in. Only 45% of doctors registered in Brazil work in primary care and almost 25% work in paediatrics and obstetrics and gynaecology despite a choice of 53 specialties.
There are also challenges around how the workforce is distributed across the country. Socioeconomic disparities mean that some municipalities look like Belgium and others look like India in terms of health indicators. A shortage of doctors in rural areas and a lack of comprehensive infrastructure mean that patients do not always have access to basic drugs for common conditions such as hypertension and diabetes.
The distribution of doctors is strongly skewed towards the southeastern and southern regions, the richest and most urbanised areas of the country. In the southeast, for example, the doctor to patient ratio is 2.61 per 1000, a world away from the 0.98 ratio in the north. Brasilia, the federal capital, has 4.02 doctors/1000.
“It is a huge challenge to offer universal health in a country with continental dimensions like Brazil. But we are experiencing a situation where cities with good infrastructure and working conditions [inland cities] are not succeeding in attracting doctors,” admits health minister Alexandre Padilha.
The government’s attempts to attract Brazilian doctors to poorer areas were unsuccessful, filling only 938 of the 15 460 places on offer. So in August 2013, as part of the “Mais Medicos” (More Doctors) programme, it recruited more than 4000 doctors from Cuba and several thousands from other countries to work in Brazil, particularly in primary care in rural areas. 
Public versus private sectors
The “More Doctors” programme sought to address the perceived shortage of doctors, but for many experts the real inequalities are caused by the public-private split in the country, which is causing problems in the distribution of doctors and workforce planning. “In a way we can say there is an identity crisis in Brazil. We have a hybrid system where the constitution grants universal coverage by the SUS but where the legislation permits overlapping between the two sectors. At least half of all Brazilian doctors work in both the private and the public systems, and that is not feasible for a country that wants to have 100% access to public medicine. We are trying to emulate the British NHS without creating conditions for it to do so,” says Mario Scheffer, a professor in the department of preventive medicine at the University of São Paulo and one of the authors of a landmark study on demographics published last year.
Medical students are drawn to work in the private sector after they graduate. “The private sector in Brazil is much more attractive, not only because it offers more competitive wages. The work conditions are much better than in the SUS, which is often underfunded and forces doctors to work under even more pressure than the job requires. Many colleagues of mine intend to focus their efforts on the private sector,” says Victor Amaral, a second year medical student in Vitoria, a southeastern coastal city in Brazil.
According to government statistics, there are four more doctors per patient available in commercial hospitals than in public hospitals. But the disparity is further brought into focus by the fact that only one in four Brazilians has private health insurance, meaning that staff in state hospitals and emergency units are invariably overworked. Yet, the public sector still delivers some crucial treatments for patients in Brazil, such as dialysis, HIV care, and transplants.
“The private health sector has grown over 10% a year in Brazil and that pretty much puts even more pressure on the public sector because this expansion requires more doctors and they inevitably gravitate towards the private clinics,” Scheffer adds.
Although the expansion in university places in theory should be helping to meet the need for doctors, in practice they mirror the public-private paradox. Seventy seven per cent of the medical schools that have opened in Brazil in the past 10 years are private and tend to price out prospective students from poorer backgrounds. These students already struggle for the free places in state universities, where competition is fierce and tends to favour students from wealthier backgrounds who have stronger secondary education.
Medical students find themselves in the crossfire. There now seems to be a weight of public expectation that the new generation of doctors will meet the public health need, particularly in primary care and rural settings.
But there are concerns about whether current training will prepare medical students for dealing with the problems of rural populations. “It looks to me that our problems start at the university. The curriculum still focuses too much on hospital treatment, and we feel there is a lack of connection with the real problems afflicting the population. We know diseases reflect social and environmental factors. Doctors have to be much more than medical experts,” says Vinicius Rodrigues, from the National Association of Medical Students.
Medical students have been wary of calls to enforce compulsory rural placements as part of the curriculum in Brazil, concerned that they would affect career progression and not offer the training required to practise safely. Doctors have been portrayed as elitist professionals who sneer at jobs in rural areas, but Amaral believes the reason for their reluctance is that they will be placed outside their comfort zone and competency. “A lot of doctors are actually fearful of working at underfunded hospitals where they might be held responsible for casualties that are actually the result of systemic failure,” he says.
He also points out fears that a whole generation of doctors might refrain from properly engaging with the public sector because they believe funding problems will not be dealt with in the future. This will in turn cause widening inequalities. “The government has to address the infrastructure otherwise young doctors will simply steer away as much as they can. The SUS legislation is beautiful on paper, but in practice there are basic problems with equipment that can make the difference between the life and the death of a patient,” Amaral says.
Pull quote: “A lot of doctors are actually fearful of working at underfunded hospitals where they might be held responsible for casualties that are actually the result of systemic failure.”Fernando Duarte, journalist and media consultant, Brazil
Correspondence to: firstname.lastname@example.org
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.
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Cite this as: BMJ 2014;22:g3457