Challenges

Brazil’s constitution recognizes health as a human right and strives to provide universal health coverage and access to it for all Brazilians through their primary health-care system. Nevertheless, great disparities in health persist, with a sizable portion of the population lacking access to proper health facilities and medical professionals, a problem that principally affects the most disadvantaged and remote regions of the country, including the 34 indigenous health districts. For 22 of the 26 States in Brazil, rates were below the national average; five of these States had less than one doctor per 1,000 people, while 700 municipalities had no doctor at all.

Toward a Solution

The More Doctors (Mais Médicos) Project emerged as an agreement between Brazil and Cuba, with technical cooperation provided by the Pan American Health Organization (PAHO/WHO), as a strategy to address this issue by transforming medical education and investing considerably in primary health-care infrastructure in Brazil. It prompted a widespread exchange of knowledge between local health professionals and foreign doctors, leading to innovative practices and improved health care. The More Doctors Project was created as part of the More Doctors Programme by national law in Brazil in 2013, and the Governments of Brazil and Cuba signed a South-South cooperation agreement with PAHO to help them to facilitate the large-scale participation of Cuban doctors because of the need for a significant number of foreign doctors to meet the demands of Brazil?s poorest municipalities. PAHO facilitates the selection, transportation and integration of Cuban doctors into basic health-care teams and has already designated 11,429 Cuban doctors to specific communities.

Brazil has set as its goal an increased average of 2.7 doctors per 1,000 people (equal to the average of the United Kingdom) by 2026. Brazil’s Family Health Strategy will directly benefit from the work of the More Doctors Project to improve the self-sufficiency of local doctors and other health-care workers. In particular, it will benefit from efforts to ensure the well-being of the entire population of Brazil, thereby enabling the country to continue its trend of rapidly reducing infant and child mortality and contributing to the provision of universal health-care coverage and access for all Brazilians. The project has brought about an improved distribution of doctors across the country and will continue to contribute to reducing current inequalities in access to health and health outcomes.

The More Doctors Project has enabled a significant increase in the availability of doctors at the first level of care, approximately 18,240 currently participating from Brazil and abroad, benefiting approximately 63 million people in 4,058 municipalities. This has contributed to a lower infant mortality rate and a decrease in hospitalizations as a result of the availability of primary health care. Independent evaluations have revealed that there was an 89 per cent reduction in waiting lines, a 33 per cent increase in the monthly average number of consultations, a 32 per cent increase in doctors’ domiciliary visits, and 95 per cent user satisfaction regarding doctors?performance, while 86 per cent of the users reported improved quality of care since the arrival of additional health-care professionals.

The majority of doctors in the More Doctors Project working in municipalities with 20 per cent or more of the population living in extreme poverty are Cuban doctors. The same is true for those working in the indigenous health districts, where 99 per cent of the doctors are Cuban. Cuban doctors constitute around 62 per cent of participating doctors. Participating Cuban doctors receive degrees equivalent to those of doctors in Brazil’s public hospitals, providing excellent opportunities for knowledge exchange. They are also responsible for the monitoring and evaluation of the project and for documenting good practices and lessons learned as part of overall technical cooperation.

The project aims to set the conditions for the long-term self-reliance of human resources for health. Brazil is therefore investing in medical education for its nationals in the health workforce. The temporary migration of foreign doctors to offer immediate assistance to underserved communities has allowed the Government of Brazil to rapidly expand its universal health access. It further enabled it to initiate profound transformations in medical education, which needed to be sustained and expanded in order to produce the required number of doctors, taking into account the lag period needed for their education. The Government is investing R$5.6 million in health infrastructure, specifically in basic health-care units, and to avoid a brain drain, it aims to establish 11,500 new health-care centres by 2017 and new residency positions for specialization in primary health-care centres. The More Doctors Project fully complies with the WHO global code of practice for the international recruitment of health personnel, and Cuba has extensively contributed to reversing this brain drain by providing opportunities for free medical education for poor communities around the world (South and North) and capacity-building for self-learning.

The More Doctors Project is replicable and would potentially be beneficial in any country that decides to adopt it. Consideration should be given to the local situation, specifically its health system and political context. Brazil made a substantial economic investment to carry out the project; however, long-term benefits have proven to outweigh those investments. PAHO member States have demonstrated great interest in learning about the More Doctors Programme and its South-South cooperation initiative, the More Doctors Project.

The main beneficiaries are Brazil’s underserved communities, including indigenous populations, through improvements in Brazil’s federal, State and municipal governments, including the ministries of health and education. PAHO has focused on integrating Cuban doctors into basic health-care teams. Knowledge- sharing is one of the most important contributions of PAHO’s participation and value added. The Government of Cuba, in particular the Ministry of Public Health, has provided doctors.