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

为所有人提供全面和高质量的医疗保健是全民健康覆盖（UHC）和实现许多联合国可持续发展目标（SDG）的关键。然而，卫生专业人员的有限和不均衡分配正在阻碍许多低收入和中等收入国家在全民健康覆盖方面取得进展。了解解决卫生专业人员短缺问题的努力是否成功地改善了服务不足地区的医疗保健服务，并改善了健康结果，对于推进这一领域的卫生政策设计至关重要。巴西是一个历史上在医生可用性方面存在巨大差距的国家，农村和贫困地区的医生数量远远低于富裕的城市地区。缺乏医生意味着许多脆弱的巴西人无法从该国国际公认的初级卫生保健提供模式中受益。2013年，巴西政府启动了一项名为“更多医生计划”的重大计划，以解决服务不足地区公共卫生系统医生严重短缺的问题。这是通过扩大医学院的名额、增加对医疗设施的投资以及通过在农村和贫困地区“紧急扩大”医生队伍来实现的。后者涉及向4 004个城市分配17 000多名医生，其中60%以上的医生来自古巴，这是国际协议的一部分。医生在服务不足地区的这种前所未有的扩张，除了对卫生系统产生更广泛的影响外，还可能对健康结果和健康不平等产生重要影响。迄今为止，尚未对方案影响进行强有力的评价，妨碍了巴西和国际决策者从方案中学习。我们将评估“紧急扩展”的PMM部分，使用国家数据库的住院和死亡，这是例行收集，并进行采访，与国家政策的执行者和卫生系统的管理人员和医生在巴西的两个州。具体而言，我们将研究为什么一些城市通过了该计划，其他人没有，哪些因素影响该计划是否在当地环境中取得成功，以及如何获得和使用医疗服务可能会改变，以应对引进PMM医生的原因。我们将研究方案的影响是否因市政当局是否分配了巴西或古巴医生而不同。我们还将研究该计划是否与儿童和成人的住院和死亡人数减少有关，以及它是否减少了健康结果的不平等。该项目是巴西（巴西利亚大学和帕拉伊巴联邦大学）和英国（帝国理工学院和伦敦卫生和热带医学院）研究人员之间的合作，他们在使用定量和定性方法评价中低收入国家的卫生政策方面具有丰富的经验。我们将通过学术论坛传播我们的研究结果，并制定了一项计划，通过与联邦和州卫生部以及泛美卫生组织计划的活动，积极向巴西和国际上的主要卫生决策者传播我们的工作。巴西是联合王国官方发展援助（ODA）的合格国家。许多巴西人无法获得高质量的医疗服务。这直接影响到他们的福利，保健需求继续得不到满足，特别是在最贫穷和最脆弱的社区。在帕拉伊巴和联邦区（我们定性研究的重点管辖区），分别有22%和5%以上的人口生活在贫困中，而20%和10%的人口是文盲。该项目将评估一项具有国际重要性的卫生保健干预措施对巴西一些最脆弱社区的健康的影响。

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.