This year sees both presidential and state elections in Brazil. The country’s SUS (its national health system) is a beloved institution, established in the constitution that freed the country from military dictatorship. Right at the heart of the nation’s political debate is what Brazil should do about a chronic and growing shortage of doctors — especially in remote and poor areas. The debate has added urgency after last year’s disturbances (see, for example, this BBC story)

Here is a brief excerpt from a longer report that our colleagues at Fundamento prepared for one of our clients (both Hyderus and Fundamento are shareholder’s in Baird’s CMC, a global communications management consulting firm — this was a Baird’s CMC report). We will post another brief excerpt (on the lack of money for the Brazilian system) next week

Brazil has always had a poor distribution of physicians across the country. While some regions (above all state capitals) have four professionals for each thousand inhabitants, others do not even have one. Approximately 700 local authority areas have no doctors. The national average is 1.95 per thousand inhabitants and only the southeast region (the wealthiest in the country) has more than the 2.5 recommended by the Ministry of Health (the southeast has 2.61). On the other end of the scale is the northern region, with 0.98.

According to the experts we interviewed, the More Doctors (Mais Médicos) programme of the Ministry of Health, has strong electoral appeal but little effect on the quality of public medical care. More Doctors was a federal project which had been shelved until a series of popular street protests in mid-2013. Protesters called for better quality in public services in general, with healthcare being a main focus. In response to this demand, the government has so far imported 5,796 foreign doctors (most of them from Cuba), who are already working in 2,025 Brazilian cities and towns.

The federal government justified the need to bring in professionals from outside Brazil by saying that Brazilian doctors had no interest in working in remote and underserved areas. This contention outraged the medical profession, and many went to the airports to greet their foreign colleagues with boos and shouts of “slaves”. Shocking pictures of intimidation of the newcomers by Brazilian doctors were exploited by the government and its supporters in the media.

The emerging negative image of the Brazilian medical community led a group of medical organisations formed by the National Federation of Physicians (FENAM), Federal Council of Medicine (CFM), the Brazilian Medical Association (AMA) and the National Association of Resident Doctors (ANMR) to issue an open letter to the public in an attempt to explain. “Don’t see this as a corporatist action of those who are only concerned with their own interests, as some say. Far from it: our interest is for you to have an SUS that you dream about: universal, complete, free with equal services for all.” But it came too late and the residual feeling was that the Brazilian doctors had been guilty of xenophobia or worse. With the arrival of the Cubans, entire communities that had never before had medical care suddenly had a doctor asking if they were okay, taking their blood pressure, listening their heart, giving directions, and finally giving them care that had never existed before.

Respondents told us that their criticism of the programme was not about the importing of professionals itself but about how the foreigners were recruited. Brazil pays R$ 10,000 of the doctors’ salary directly to Cuba, and Cuba passes on to their doctors between 25 percent and 40 percent of this amount. Opponents describe this as “supporting slave labour”. One of the Cuban doctors has now sued the Brazilian government requesting her full salary (and claiming asylum in the process).

The foreign doctors also have three years in which to pass the revalidation exam, a test that every foreign doctor has to take (and pass) in order to practise legally in Brazil. The test has a history of very high failure rates and some say that the difficulty of the test is designed to prevent foreigners from working in the country. Most of the new doctors speak Spanish, not Portuguese. The two languages are cousins but there are still cases of confusion and misunderstanding.

Brazilian doctors speak Portuguese but many have trouble proving they are fit to practise medicine. In a test (not mandatory) used by the Regional Medical Board of the State of São Paulo in 2002, 54 percent of graduates from universities in the state demonstrated that they had not mastered the basic areas required to practise the profession. This happened in the state with the highest-ranked medical schools in the country and amongst doctors who volunteered to take the test. The controversies over the foreign doctors and the Brazilian exam results has led to calls for much more active surveillance of all doctors practising outside major institutions.

The image below is from the BBC story