Brazil's experiment to expand its medical workforce through private and public schools: Impacts and consequences of the balance of regulatory and market forces in resource-scarce settings.

Abstract

Background: 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.

Methods: 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.

Findings: 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.

Conclusions: 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.