The Brazilian “More Doctors” program’s dilemma
4 April 2016
In 2013, the Brazil’s Workers Party government (Partido dos Trabalhadores—PT) of President Dilma Rousseff, announced the “More Doctors” program (Programa Mais Médicos) in order to fill the shortage of doctors in the inner cities and on the outskirts of large cities in Brazil.
The program aimed to take 15,000 doctors to areas that were short on health care professionals by importing doctors from other countries, especially Cuba, through that country’s “Medical Internationalism” program that sends thousands of physicians and health professionals overseas every year.
Initially, the program was the Brazilian government’s response to the refusal of physicians working in the Unified Health System (Sistema Unico de Saude-SUS), Brazil’s publicly funded health care system, to work in the country’s more remote areas. Most doctors argued that the working conditions in these areas, compared to bigger cities, were too risky even with the government offering slightly higher wages.
Twenty-two out of 27 states in Brazil have less than two physicians per 1,000 inhabitants. About 8 percent of doctors in the country work in cities with less than 50,000 people, which makes up approximately 90 percent of Brazil. Only major cities such as São Paulo, Rio de Janeiro and Curitiba have enough available physicians, as their levels surpass the national average. Meanwhile, states such as Maranhão, Alagoas and Amapá have serious problems with shortages of doctors, with an average of one doctor per 1,000 inhabitants.
In 2011, the solution offered by Brazil’s PT government was to create a program to attract young physicians to regions where there were less than two doctors per 1,000 inhabitants, by offering monthly wages of R$ 8,000 (U$ 2,129). However, the reception did not reach the expectations of the federal government. Of the 13,000 doctors needed in 3,000 cities across Brazil, only 4,392 professionals responded to the application and 3,800 ended up moving to the places that required doctors. Thus, the Brazilian government’s solution to fill the gap in the small towns and rural areas was to “import” doctors from overseas, mainly Cubans.
Medical institutions and doctors from all parts of the country reacted with anger and criticism to the “More Doctors” program, accusing the Workers Party of helping the “Cuban dictatorship” and “importing Castro’s agents disguised as doctors.”
Conservative segments from medical institutions such as the Federal Medical Council and several Doctors Trade Unions throughout the country claimed that the “More Doctors” program was PT’s strategy to win the presidential election in 2014.
With Brazil’s minimum monthly wages set at R$ 880 (US$ 234), a doctor’s actual income may reach R$ 10,000 (US$ 2,662) per month. In a country with a large inequality gap, at public federal universities, which are tuition free, medical schools are filled with upper middle class students.
That a recent poll by the São Paulo Regional Medical Council found that 74 percent of medical students are white compared to 2.3 percent who are Afro-Brazilians, who constitute roughly half of the population but are predominantly poor, is an indication of the country’s class-based medical system.
Another research study from National Exam for the Assessment of Student Performance—Enade—revealed that most medical school students belong to families with incomes of 10 to 30 times the minimum wage monthly, equivalent to R$ 6,780 to R$ 20,340 (U$ 1,805 to U$ 5,415) per month. The same study showed that 84 percent of medical students do not have a part-time job and most have their education paid for by their parents. This data confirms that most of the men and women who are attending medical schools come from privileged backgrounds.
This privilege also affects the future physician’s decision to work for the private sector instead of the SUS and to pursue a specialization instead of becoming general practitioners, which are in constant demand in the remote areas of the country. Recently, when asked why medical students are not interested in working for the public health system, the Coordinator of the Medical School at the Federal University in Alagoas Francisco Passos said that most medical students in federal institutions consider “poor, African descendants and indigenous populations as mere guinea pigs”.
Brazilian medical elitism became even more evident after the “More Doctors” program, which has revealed a new “angry and racist” side of many Brazilian doctors and their legal representatives. When Cuban doctors started to arrive at the Brazilian airports coming to work for the new program, doctors from different regions in Brazil gathered at the terminals to protest against them. On social media, white privileged Brazilian doctors wrote hate messages stating that the “Cuban doctors didn’t look like real doctors because they were dark skinned and looked more like servants or maids”.
The tension between doctors and other workers in the country also demonstrates the contradictions of the populist agenda led by the Workers Party over more than a decade.
As the Workers Party government tries to solve a serious problem by bringing doctors from other countries—sometimes without a contract, a decent salary or good working conditions—the government also ignores the real demand from the Brazilian population, especially from the working class and poor to strengthen the universal healthcare program—SUS.
But such a goal could only be achieved with public universal healthcare available to everyone, which would attract new doctors who could work under good conditions and at the same time would offer better services to the population, especially for those who cannot afford private health care. According to World Health Organization, Brazil invests less than 9 percent of its budget in public healthcare.
Ironically, earlier this year, the Brazilian Congress—which is the most conservative it has been since 1964 (prior to the coup d'état by the military)—approved a bailout of Private HealthCare Plans for more than R$ 2 billion (U$ 532 million). This only shows that the Brazilian government’s lack of interest in investing in the public health system also has to do with the elite’s plan of sabotaging SUS as an excuse for privatizing the system.
As Brazil debates the lack of physicians in the country, the Federal Medical Council fears the opening of new universities, especially private ones, claiming that it would hurt the quality of the medical curriculum, which could be compromised by deregulation and less qualified professors. Critics of the Federal Medical Council claim that the the institution’s boycott has more to do with controlling the number of doctors in the country, thus keeping wages high, rather than any genuine concern for the quality of education in medical schools.
Last year, during the one year anniversary celebration of the “More Doctors” program, Ana Luiza, a medical school student at the Federal University in Rio Grande do Norte (UFRN) in northeastern Brazil, expressed her support for the program by explaining the positive impacts, especially for poorer families.
Doctors and medical students from all over Brazil reacted in outrage over Luiza’s statement, writing hate messages to her and attacking the student on social media. At the same time, a recent poll by the Federal University of Minas Gerais showed that most of the SUS patients approve the “More Doctors” program and rated the Cuban doctors as more “humane” than their Brazilian counterparts.
The contradictions of the “More Doctors” program are emblematic of the profound political crisis gripping the PT government amid the drive to impeach President Rousseff. By fully subordinating its policies to the profit interests of international and Brazilian capital, while pursuing minimal social assistance programs to ameliorate glaring social inequality, the Workers Party has succeeded in enraging sections of the middle class, even as it fails to stem the deepening immiseration of the working class and poor caused by the capitalist economic crisis.
A genuine answer to the lack of doctors for large sections of the Brazilian population can be found only through establishing truly free, high quality and universal health care. This requires reorganizing the entire health care system under workers’ control and on socialist foundations that place the social rights of the working class above the profit drive of the Brazilian capitalists and the transnational banks and corporations. The realization of such a program is possible only through the building of a new revolutionary party of the working class.