Health System and Medical Education in Brazil Milton A. Martins Professor of Medicine University of Sao Paulo Medical School

Overview Something about Brazil Health System Physicians: number and distribution Medical Education Training of Specialists

Countries by Area (Km 2 ) 1 Russia 17,098,242 2 Canada9,984,670 3 China9,572,900 4 United States9,526,468 5 Brazil8,515,767 6 Australia7,692,024

Countries by Population 1 China1,366,210,000 2 India1,248,060,000 3 United States318,577,000 4 Indonesia252,164,800 5 Brazil203,010,000 6 Pakistan188,020,000

Countries by Gross Domestic Product (millions of US dollars) 1United States16,244,600 2China8,358,400 3Japan5,960,180 4Germany3,425,956 5France2,611,221 6United Kingdom2,471,600 7Brazil2,254,109 8Russia2,029,812

But.... Gross National Income per Capita Brazil ranks 52nd (U$ 11,630) And Human Development Index (HDI) Brazil ranks 79th

Brazil

Sao Paulo – Metropolitan Area Total area – 8,500 Km 2 Urban area – 2,200 Km 2 19,822,572 inhabitants (2011)

Sao Paulo

Brazil: Health Challenges of Developed and Developing World Burden of diseases include -Aging of population -Chronic diseases (cardiovascular and cancer) -Urban violence and motor vehicle accidents -Infectious diseases, old and new -Mental health

Brazil: Health Challenges of Developed and Developing World We have very good public organ transplantation system, comprehensive care of people who live with HIV/AIDS and immunization coverage. In contrast, we will not be able to reach the millennium development goal of reducing maternal mortality. We have not been able to eradicate congenital syphilis and have a high prevalence of Hansen’s disease.

Brazilian Health System (1988) Since 1988, Brazil has developed a dynamic, complex health system (the Unified Health System, SUS), which is based on the principles of health as a citizen’s right and the state’s duty. The SUS aims to provide comprehensive, universal preventive and curative care through decentralized management and provision of health services and promotes community participation at all administrative levels.

Brazilian Health System (1988) Implementation of SUS has been complicated by state support for the private sector, the concentration of health services in more developed regions, and chronic underfunding. Brazil invests less than 4% of his gross national product in the public health system.

Primary Care in Brazil The expansion of primary care has been achieved mainly through the creation of the Program of Family Health (Programa de Saúde da Família – PSF) PSF works through family health-care teams, which are generally composed of one doctor, one nurse, one auxiliary nurse and four to six community health workers, and, since 2004, oral health teams. Each team takes care of families. There are about 33,000 family health care teams, reaching about 100 million people.

Physicians/1000 population WHO regions African Region0.25 Region of the Americas2.04 South-East Asia Region0.55 European Region3.33 Eastern Mediterranean Region1.08 Western Pacific Region1.52 Brazil1.76 World Health Statistics 2013 (WHO)

Physicians/1000 population Income Groups Low income0.51 Lower middle income0.78 Upper middle income1.78 High income2.71 Brazil1.76 World Health Statistics 2013 (WHO)

Total number does not meet society’s needs Regions of the country Large and small cities Central and peripheral areas of large cities Public and private sectors of the health system Brazil: Unequal Distribution of Physicians

Brazil: Unequal Distribution of Physicians (Physicians/1000 population) State Maranhão0.64 Pará0.80 Acre0.92 Piauí0.94 State Distrito Federal3.83 Rio de Janeiro3.52 São Paulo2.50 Rio Grande do Sul2.31

Medical Education in Brazil Medical course in Brazil is a 6-year program, usually with two years of basic sciences, two years of clinical sciences and two years of clerkships (internship). Professional education has not kept pace with the challenges of the health systems in the world. This is the same in Brazil, although there has been a substantial effort to change education of health professions to meet the society needs.

Medical Education Guidelines in Brazil The guidelines for medical education established in 2001 define that medical schools must give a generalist formation and that the major determinant of the curricula in medical schools must be the health needs of the population and the training of medical students must be in all levels of the health system. Almost all medical schools of Brazil developed programs to reorient their curricula to shift training from tertiary hospitals to clinics and communities.

Medical Education Guidelines in Brazil The new guidelines for medical education published this year by the Ministry of Education state that at least 30% of the last years of medical education (internship) must be composed of primary care and emergency care in the Brazilian Heath System (SUS).

Increase in the Number of Medical Schools in Brazil In the last years, there has been a substantial increase in the number of Medical Schools in Brazil, mainly of private schools. Both the Brazilian Medical Association and the Brazilian Association of Medical Education oppose this increase. We believe that there are enough Medical Schools in Brazil. There are also concerns about the quality of many of these new Medical schools.

Medical Schools in Brazil

First Year Medical Students in Brazil

Percentage of physicians that live in the state of Brazil where they went to Medical School (Seixas et al) 0 to 21%0 21 to 41%4 41 to 61%7 61 to 81%12 81 to 100%1

Percentage of physicians that live in the state of Brazil where they went to Medical Residency (Seixas et al) 0 to 21%0 21 to 41%0 41 to 61%1 61 to 81%6 81 to 100%16

Medical Residency in Brazil Medical Residency is not mandatory to work as a physician in Brazil. In the last years, there has been a substantial increase in the number of Medical Residency Programs in Brazil. There are about 2,000 more graduates in Medical School than available positions for Residency. According to a recently approved law (2013), there will be enough positions of Residency for all graduates from Medical School by This increase will be mainly in Residency in Family Medicine (Family and Community Medicine in Brazil).

Number of Positions Available for Graduates in Medical Schools Internal Medicine2,620 General Surgery1,830 Pediatrics1,743 Family and Community Medicine1,260 Gynecology and Obstetrics1,144 Orthopedics894 Anesthesiology887 Psychiatry524 Radiology496 Ophthalmology460 Dermatology237 Otorhinolaryngology233 Total13,542

Residency in Surgery in Brazil Two years of General Surgery. The majority of residents decide to go to a second Residency, in a subspecialty (Plastic Surgery, Urology, Vascular Surgery, Cardiac Surgery, Thoracic Surgery, Abdominal Surgery...)(2-3 more years). Most surgeons believe that two years of training are not sufficient for a general surgeon. There are a few programs of General Surgery of 4 years, in some Academic Health Centers.

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