Inequalities in healthcare and medical education in Brazil
Brazil is a continental country with its population concentrated in the coastal, urban areas. After two decades of rule by military government, a new constitution was ratified in 1988, and with it came a public health system that was free of charge to the Brazilian population. Although the public healthcare system has contributed to a steady and widespread improvement in health indices over the past three decades, large inequalities persist. For example, a Lancet article in 2011 reported that child mortality rate in Northeastern Brazil was 2.24 times higher than in Southern Brazil.
Most medical education takes place in the public health system. Medical students like me are able to see at first hand the consequences of healthcare disparities. Even though access to primary care has evolved, its capacity for resolving cases is still low. Primary care physicians, for example, often have limited access to further investigations, forcing them to help patients cope with serious conditions while they wait for a specialist appointment. This has led to measures such as “ambulance therapy,” whereby instead of investing in local health infrastructure cities purchase vans and buses to take citizens to cities for their healthcare.
Attracting doctors to work in remote areas is a challenge in Brazil. Medical students and newly graduated doctors are the main targets of attempts by the government to reduce the deficit. As part of the Mais Médicos (More Doctors) programme, which was launched in July 2013, a “curriculum reform” was announced. A two year mandatory internship in a remote area in primary care would be added on top of the already existing two year mandatory internship, which includes rotations in the main fields of medicine but not necessarily in remote areas. In the internships in rural areas medical students would be expected to attend to outpatients while under the supervision of a local doctor. Critics doubted that the proposal would provide adequate training and supervision, and thought that medical students would end up being a low paid workforce on a type of mandatory national service. This proposal was dropped, but bills aiming to create a mandatory service for young doctors to work in inland areas have become more common over the past few years.
Few medical students in Brazil plan on working in smaller towns. Many were born in larger cities and are used to the lifestyle. In general, the better paid, stable jobs are in large cities. Recently, there has been a public backlash against doctors who refuse to work in more remote areas. Creating the right conditions for doctors to want to work in these areas should be a priority. Staff turnover in primary care in Brazil is high—primary care is seen as a temporary job, a step towards a more solid future, usually in more valued specialties. I believe that the solution includes mapping out a clearer career progression for doctors entering primary care, with the guarantee of stability, good career opportunities, and improving the availability of tests and treatments for patients in remote areas.Ricardo Dahmer Tiecher, fifth-year medical student
1Federal University of Rio Grande do Sul, Porto Alegre, Brazil
Competing interests: RDT is an exchange student through the Science without Borders program from CAPES Foundation (a federal scientific funding agency). He has received Scientific Initiation stipends from Fapergs and CNPq in 2012 and 2013 (a state and a federal funding agency, respectively). This article reflects exclusively his personal opinion.
Provenance and peer review: Not commissioned; not externally peer reviewed.
- Jairnilson P, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet 2011;377:1778-97.
Cite this as: Student BMJ 2014;22:g3543