Evaluating the impact of the Mais Médicos (More Doctors) programme in Brazil

Providing access to comprehensive and high quality healthcare for all is key for Universal Health Coverage (UHC) and for achieving many of the United Nation's Sustainable Development Goals (SDGs). However, the limited and uneven allocation of health professionals is undermining progress towards UHC in many low and middle income countries (LMICs). Understanding whether efforts to address shortages in health professionals are successful in improving access to healthcare in underserved areas and produce improvements in health outcomes is crucial for advancing the design of health policy in this area.

Brazil is a country that has historically suffered large disparities in doctor availability with rural and poor areas having a much lower provision of doctors that wealthier, urban areas. This lack of doctors means that many vulnerable Brazilians are not benefiting from the country's internationally recognised model of primary health care delivery. In 2013, the Brazilian government launched a major programme called Programa Mais Médicos (PMM) or More Doctors programme to address acute shortages of doctors in the public health system in underserved areas. This was achieved by expanding medical school places, increasing investment in healthcare facilities, and through an "emergency expansion" of doctors in rural and poor areas. The latter has involved the allocation of over 17,000 doctors to 4,004 municipalities, with more than 60% of these doctors coming from Cuba as part of an international agreement. This unprecedented expansion of doctors in under-served areas may have important effects on health outcomes and health inequalities, in addition to wider health system impacts. To date, no robust evaluations of programme impacts have been undertaken, hampering learning from the programme for policymakers in Brazil and internationally.

We will evaluate the "emergency expansion" component of PMM using national databases of hospitalisations and deaths which are routinely collected and by conducting interviews with national policy implementers and health system managers and doctors in two states of Brazil. Specifically, we will examine the reasons why some municipalities adopted the programme and others did not, which factors influenced whether the programme was successful in local settings and how access and use of health care services may have changed in response to the introduction of PMM doctors. We will examine if programme impacts differed by whether municipalities were allocated Brazilian or Cuban doctors. We will also examine whether the programme was associated with a reduction in hospital admissions and deaths, both in children and adults, and whether it reduced inequalities in health outcomes.

The project is a collaboration between researchers based in Brazil (University of Brasilia and the Federal University of Paraiba) and in the UK (Imperial College and the London School of Hygiene and Tropical Medicine) who have extensive experience in evaluating health policy in LMICs using quantitative and qualitative methods. We will disseminate our findings through academic forums and have developed a plan to actively disseminate our work with key health policy makers in Brazil and internationally, through events planned with Federal and State Ministries of Health and the Pan-American Health Organisation (PAHO).

Brazil is an eligible country for UK official development assistance (ODA). Many Brazilians cannot access quality healthcare services. This directly affects their welfare, and health needs continue to go unmet - particularly in the poorest and most vulnerable communities. Over 22% and 5% of the population live in poverty in Paraiba and the Federal District (the focus jurisdictions for our qualitative research) respectively, whilst 20% and 10% are illiterate. This project will evaluate the impact of an internationally important HRH intervention on the health of some of Brazil's most vulnerable communities.

The Programa Mais Médicos (more doctors programme) (PMM) is a key strategy to expand Brazil's family health strategy in underserved areas. Little robust evidence exists on the impact of interventions to increase human resources for health (HRH) such as the PMM on access to healthcare, health outcomes, and wider health system impacts. The evidence gap is largest in low- and middle-income countries where distributional inequalities in HRH are greatest. Robust impact evaluations of the PMM as an internationally recognised supply-side intervention is vital to inform HRH policy in Brazil and globally.

We plan to evaluate the PMM using quantitative and qualitative methods. We will conduct quantitative analysis of all municipalities for national generalizability. For qualitative analyses, we will select 24 municipalities in the Integrated Development Region of the Federal District (RIDE/DF) and the state of Paraiba that have introduced PMM doctors. We will conduct a quasi-experimental evaluation of routinely available data using difference-in-difference methods to assess the impact of the PMM on mortality and morbidity. We will expand these analyses to examine heterogeneity of impact across programmatic factors (e.g. different municipalities and types of doctors) and population characteristics (including age, sex and racial groups) to draw inference on health inequalities. We also plan to evaluate whether PMM uptake across municipalities was in line with Federally-established criteria of need, and what effect expansion in non-priority municipalities may have had on overall impact. We will conduct qualitative research in the form of clinic observation and semi-structured interviews with national implementers, local health managers and PMM doctors to better understand facilitators and barriers to successful implementation, including broader health system constraints and how these were addressed by managers and clinicians.

This research will have direct relevance to health system policy-makers both within Brazil and other low- and middle-income countries, and support evidence-based decision making. Currently, there is weak evidence on relationship between investment in human resources and health outcomes, health inequalities and the wider health system impacts. Brazil, as an ODA country, has suffered geographical and sectoral inequalities in doctor distributions affecting the welfare of the poorest and most vulnerable Brazilians. This project can directly contribute to overcoming these challenges.

Our primary beneficiaries will be Brazilian health policy-makers and local health managers, whilst indirect beneficiaries include the Brazilian population and health workers. We plan to maximise impact within Brazil through a range of actions. As noted in our Pathways to Impact statement, several key health system and PMM stakeholders have agreed to serve on our Project Steering Committee (PSC). These come from a range of organisations including the Ministry of Health, PAHO, other Brazilian and international universities, primary care managers, and patient representatives (see full list below). This will ensure that our research is policy relevant and has a well-developed platform for dissemination. Our outputs will be published in high-impact journal articles both in English and Portuguese and presented at conferences and health policy forums in Brazil. We plan an active engagement of academic and policy community and the public with our research through both traditional and social media. We will disseminate findings through civil society and other actors engaged in the health fields (e.g. PAHO, CONASEMS, and ABRASCO) to maximise uptake and inform evidence-based policy makers. We plan to hold workshops and dissemination events in collaboration with PAHO Brazil and provide feedback of our emerging study findings of health managers and PMM doctors who participate in our interview study through regular study bulletins. All these actions have the intention of timely feedback of results, wide dissemination of findings, and engaging a range of actors, with the overall aim of influencing health policy.

We will draw on our network of experts within PAHO and the WHO to ensure dissemination of our findings to other regions of the world. Members of our research team have extensive experience of participating in health policy workshops and meetings with regional and international health agencies. There will be substantial benefits to the academic community, especially for early career researchers based in Brazil. They will benefit from new international collaborations, exchange activities, conference attendance, exposure to new research methods, and involvement in dissemination activities (see Academic Beneficiaries for further details). Policy-makers in the research group will benefit from better understanding of health services research and how to engage effectively with the academic community to optimise policy relevant research outputs.

Individuals that have agreed to join our Project Steering Committee:

Carlos Rosales / Joaquin Molina - PAHO Brasil
Filomena Fernandes Valadares - Councillor of the Regional Health Council
Rodrigo Morena-Serra - University of York
Claudia Medina Coeli - Federal University of Rio de Janeiro
Adriano Massuda - Harvard School of Public Health
Camile Giaretta Sachetti - Director of the Department of Science and Technology in the Ministry of Health
Adelson Guaraci Jantsch - Coordinator of the Family and Community Health Residency Programme in the Municipal Secretariat for Health in Rio de Janeiro