Public Health Policy Evaluation Unit, Imperial College London, London, UK.
Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
BMC Health Serv Res. 2020 Sep 15;20(1):873. doi: 10.1186/s12913-020-05716-2.
Investing in human resources for health (HRH) is vital for achieving universal health care and the Sustainable Development Goals. The Programa Mais Médicos (PMM) (More Doctors Programme) provided 17,000 doctors, predominantly from Cuba, to work in Brazilian primary care. This study assesses whether PMM doctor allocation to municipalities was consistent with programme criteria and associated impacts on amenable mortality.
Difference-in-differences regression analysis, exploiting variation in PMM introduction across 5565 municipalities over the period 2008-2017, was employed to examine programme impacts on doctor density and mortality amenable to healthcare. Heterogeneity in effects was explored with respect to doctor allocation criteria and municipal doctor density prior to PMM introduction.
After starting in 2013, PMM was associated with an increase in PMM-contracted primary care doctors of 15.1 per 100,000 population. However, largescale substitution of existing primary care doctors resulting in a net increase of only 5.7 per 100,000. Increases in both PMM and total primary care doctors were lower in priority municipalities due to lower allocation of PMM doctors and greater substitution effects. The PMM led to amenable mortality reductions of - 1.06 per 100,000 (95%CI: - 1.78 to - 0.34) annually - with greater benefits in municipalities prioritised for doctor allocation and where doctor density was low before programme implementation.
PMM potential health benefits were undermined due to widespread allocation of doctors to non-priority areas and local substitution effects. Policies seeking to strengthen HRH should develop and implement needs-based criteria for resource allocation.
对卫生人力（HRH）进行投资对于实现全民健康覆盖和可持续发展目标至关重要。“Mais Médicos”（更多医生）项目为巴西初级保健提供了 17000 名医生，他们主要来自古巴。本研究评估了该项目向各城市分配医生的情况是否符合项目标准，并评估了其对可预防死亡率的影响。
利用 2008 年至 2017 年期间在 5565 个城市实施“Mais Médicos”项目的变化，采用差分法分析评估该项目对医生密度和可通过医疗保健治疗的死亡率的影响。从医生分配标准和项目实施前城市医生密度两个方面对效应异质性进行了探讨。
“Mais Médicos”项目于 2013 年开始实施，项目实施后，每 10 万人中初级保健合同医生人数增加了 15.1 人。然而，由于现有初级保健医生大量被替换，每 10 万人中实际增加的医生仅有 5.7 人。由于分配给“Mais Médicos”项目的医生数量较少，以及替代效应较大，优先城市的“Mais Médicos”项目和初级保健医生人数增加较少。“Mais Médicos”项目使可预防死亡率每年降低 1.06 人（95%CI：-1.78 至-0.34），在优先考虑医生分配的城市和项目实施前医生密度较低的城市，其效果更为显著。
由于医生广泛分配到非优先地区和当地的替代效应，“Mais Médicos”项目的潜在健康效益受到了损害。寻求加强卫生人力的政策应制定和实施基于需求的资源分配标准。
