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

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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.