Scheffer Mário, Mosquera Paola, Cassenote Alex, McPake Barbara, Russo Giuliano
Preventative Medicine Department, Faculty of Medicine, University of São Paulo, Avenida Dr. Arnaldo, 455, 2º andar, sala 2166, São Paulo, CEP: 01246-903, Brazil.
Melbourne School of Population and Global Health, The University of Melbourne, Level 4, 207-221 Bouverie St, Melbourne, VIC, 3010, Australia.
Global Health. 2025 Mar 28;21(1):14. doi: 10.1186/s12992-025-01105-8.
There is a global shortage of doctors, and governments worldwide are concerned with expanding national medical workforces to improve services. Since 2013 the Government of Brazil has introduced the Mais Médicos (More Doctors) Legislation (MML), which included policies to liberalise the medical education market and boost deployment to rural areas, and implemented quotas in public universities to improve diversity in the supply of physicians. Such experience provides an insight for the global debate on the role of the private sector in medical education.
We draw from the analysis of unique medical demography datasets to assess the impact of those policies on the number and distribution of doctors and medical students, composition of the workforce, and quality of training. To analyze the increasing trend of students and physicians, interrupted time-series analysis was conducted using segmented linear regression, comparing two time periods considering the MML as the start of the intervention. Staff-to- student ratios and ENADE educational attainment data were used to compare the quality of teaching between public and private institutions.
Within the context of Brazil's population and economic growth over the last decades, we find that since 2003 Brazil has almost doubled its medical workforce to 2.77 per 1,000 population, with the largest increase recorded after the 2013 legislation. Our analysis shows such growth has benefited poorer, remote states, although the bulk of new doctors and students are still located in the country's richer regions. The diversity of medical students increased significantly since the More Doctors Legislation, with more female (61.4% in 2023 as opposed to 55.5% in 2013), and mixed-race enrolments (25.5% and 19.4%). However, medical students are still predominantly white (68.7% and 71.6%), and from fee-paying secondary schools (68.1% and 75.8%). Comparison of student achievement scores and of deployed resources also show a significantly lower quality of teaching in private medical schools.
We conclude that Brazil's policy approach has delivered a substantial overhaul of its medical workforce through a combination of public and private sector policies. However, progress in students' diversity and quality of education has been mixed. Brazil's experiment suggests that private schools can be an option for rapid health workforce expansions in middle-income economies. However, close monitoring of their outputs would be needed, as our analysis shows they do little to address inequalities, and casts doubt on the quality of the training offered.
全球医生短缺，世界各国政府都在关注扩大本国医疗人力以改善医疗服务。自2013年以来，巴西政府出台了《更多医生》立法（MML），其中包括放开医学教育市场和增加农村地区医疗人员配置的政策，并在公立大学实施配额制以提高医生供应的多样性。这种经验为全球关于私营部门在医学教育中作用的辩论提供了见解。
我们通过对独特的医学人口统计学数据集进行分析，以评估这些政策对医生和医学生数量及分布、劳动力构成以及培训质量的影响。为分析学生和医生数量的增长趋势，使用分段线性回归进行中断时间序列分析，比较将MML视为干预开始的两个时间段。师生比和全国高等教育入学考试（ENADE）教育成就数据用于比较公立和私立机构的教学质量。
在巴西过去几十年的人口和经济增长背景下，我们发现自2003年以来，巴西的医疗人力几乎翻了一番，达到每1000人中有2.77名医生，2013年立法后增长最为显著。我们的分析表明，这种增长使较贫困的偏远州受益，尽管新增医生和学生大多仍集中在该国较富裕地区。自《更多医生》立法以来，医学生的多样性显著增加，女性（2023年为61.4%，而2013年为55.5%）和混血学生（分别为25.5%和19.4%）的入学人数增多。然而，医学生仍然主要是白人（分别为68.7%和71.6%），且来自付费中学（分别为68.1%和75.8%）。学生成绩得分和配置资源的比较也显示私立医学院的教学质量明显较低。
我们得出结论，巴西的政策举措通过公共和私营部门政策的结合，对其医疗人力进行了大幅改革。然而，在学生多样性和教育质量方面的进展参差不齐。巴西的试验表明，在中等收入经济体中，私立学校可以成为快速扩大卫生人力的一种选择。然而，需要密切监测其产出，因为我们的分析表明它们在解决不平等问题方面作用不大，且对所提供培训的质量存疑。
