Masters Thesis reveals the importance of physician supply programs in Brazil and the challenges to address vulnerability in indigenous health care

The difficulty ensuring the presence of physicians in the most vulnerable, hard-to-reach territories with ethnic/cultural specificities and with a differentiated work process extends the indigenous populations vulnerabilities, including for neglected diseases


The study also shows that 57.1% of the professionals were concentrated in the North, followed by 20.5% in the Northeast, regions known for the absence of doctors in their teams, as well as their difficult fixation

The lack of medical professionals in remote areas is a worldwide concern. Brazils indigenous lands historically have difficulties having physicians in their health teams due to access challenges and to the ethnic-cultural diversity, especially in the North and Northeast, and particularly in the Legal Amazon.

In addition to the question of access of these professionals, the main challenges are the difficulty service organization within these territories, purposing to operationalize one of the Unified Health Systems (SUS) principles: total health. Based on the National Indigenous Peoples Health Policy (PNASPI), the Brazilian indigenous territories were organized in Special Indigenous Sanitary Districts (DSEIs), and 34 Districts were created according to the demographic, cultural, social and economic aspects of each indigenous peoples. These districts were strategically divided according to territorial and geographical criteria of the indigenous communities, and not necessarily by Municipalities and / or States; being responsible for carrying out activities in the indigenous territory, aiming at health care qualification measures.

After the creation of the More Doctors Program [Programa Mais Médicos] (PMM), the scenario of scarcity and the absence of doctors has been transforming into indigenous health. The Master’s thesis in Collective Health defended in December,2018 by Fátima Sonally Sousa Gondim, under the guidance of Professor Maria da Graça Luderitz Hoefel and entitled More Doctors in Indigenous Health in Brazil: profile and coverage in the Indigenous Health Districts – DSEIs, brings revealing data.

Fátima Sonally reveals in this study carried out in 2017 that indigenous health had by then 352 physicians of the More Doctors Program working in Primary Health Care (PHC) in these territories. According to data from the Ministry of Healths Special Secretariat for Indigenous Health (SESAI/MS), in the first year of the Program, in 2013, 310 physicians were enrolled, and in the first two years, 339 doctors joined the DSEIs. This represented a 79% increase over the number of physicians working in these areas in August 2013. The MDP is considered one of the greatest positive impacts for the increase in health services coverage and access in PHC, what does not differentiate from indigenous health. In addition, the results also show that 88,4% of the doctors are male and Cuban (87.8%).

The study also shows that 57,1% of professionals were concentrated in the North, followed by 20.5% in the Northeast. These regions have always been marked by the absence of the medical professional in their teams, as well as the difficult fixation of these, especially in the North, more precisely in the Legal Amazon. These regions are considered to be more vulnerable, with more complex territorial and logistic specificities. This evidences the lack of care in these regions, since they are seen as less attractive by health professionals.

The physicians rate per person was 7 for every 10 thousand indigenous people in 2017, with medical assistance in each of the 34 DSEIs. Ten districts had this rate composed totally by physicians within the Program (Parintins, Cuiabá, Alto Rio Purus, Alto Jurua, Xavante, Médio Purus, Amaá/North of Pará, Kaiapo do Pará, Xingu and Altamira), what becomes extremely important since it evidences the importance of the Program, especially the international cooperation, as a strategy that allowed and ensured the presence of physicians in the North and Northeast regions, particularly in those considered difficult to access.

As a conclusion, Fatima Sonally says the PMM is considered a major milestone for indigenous health, with great participation of international cooperation, since until mid-November 2018, 87.8% of the professionals working in these territories were foreigners, and this kind of recruitment was successful in the fixation of physicians in unassisted areas with lack of these professionals.

In face of the current scenario, changes in the physician provision program in the Country, especially after ceasing the Cuba-Brazil cooperation, some concerns pointed by the authors make us reflect on some questions: which measures will be taken to fill those vacancies where they were previously first offered in a public notice for Brazilians and since they were not filled, were they replaced by Cubans? Which strategies will be deployed to anchor physicians in vulnerable and hard-to-reach regions? What actions related to medical training should be taken to bring students and PHC professionals closer, and why not also indigenous health, since this population has an epidemiological profile different from the general population?

In fact, expanding the multiple dimensions of the indigenous populations vulnerabilities increases the concerns of the Brazilian Society of Tropical Medicine for the occurrence of neglected tropical diseases. A study that assessed neglected diseases in Brazil and vulnerability and challenges aspects, published by the Ministry of Health, under technical supervision by Prof. Dr. Alberto Novaes Ramos Jr. from the Federal University of Ceará – Chapter 5 Neglected Tropical Diseases in Brazil: vulnerability and challenges in Brazilian Health 2017: an analysis of the health situation and challenges to reach the sustainable development goals  revealed greater detection rates of this group of diseases among indigenous populations.

This study by the University of Brasilia (UnB) has a great contribution for the creation of evidences that can support the Ministry of Health to find strategies that enhance and strengthen the Program as well as, favors and ensures the presence of physicians in these so vulnerable, hard-to-reach territories with ethnic/cultural specificities and of differentiated work process, and thus, contribute to the enhancement of Primary Health Care in the Unified Health System.