Eixo formação do programa Mais Médicos e os preditores de fixação em áreas desassistidas no estado da Bahia: análise sob a ótica do ciclo de políticas de Stephen Ball

Abstract

This thesis consists in an analysis of the axis Education of the Mais Medicos Program, specifically around the changes in the education in Medicine, as a strategy for facing the issue of the lack of physicians in Brazil. A mixed qualitative and transversal-quantitative methodology was adopted, with the aim at evaluating the effects of the policy in the face of the several main educational predictors of the fixation of physicians in the Primary Health Care in unassisted areas, from the approach of the Policies Cycle of Stephen Ball. The first stage in the study identified the main educational predictors for fixation related to the graduation in Medicine, through a narrated review of the international literature. The selection processes prioritizing native or in-resident students in regions where there is a lack of that professional, also who are from a populational background that has difficulty in access to health services as the main predictor, reiterating previous studies. The location and public or private nature of the medical schools were also defined as important predictors. The quality of the education was characterized by the adoption of curricular structures with problematizing methodologies focused in local health issues, and with emphasis in the clinical approaches that are specific of the Primary Care, of the Family Medicine and also of Rural Medicine; by the education and teaching experience, and by the local health services infrastructure. After that, the effects of the axis Education were analysed in the face of the identified predictors. The location and nature of the new positions in Medicine schools created by the program were analysed in the macro-political scenario thorough a documental research. The Education axis revealed itself to be a potent policy in face of the results presented, such as the change in the regulation of high schools, with the actualization of the Single Healthcare System as educating professionals, and the interiorization of new courses of medicine, created from the program. However, the vacancies were more predominant in the South-East region, and in private institutions. The second stage of the research was done with the new courses of medicine that were created in four federal universities of the state of Bahia. The effects of the program in relation to the adequate selection of the students and the quality of the education were analysed through interviews with professors and through online questionnaires with students. The results showed that the new courses created in Bahia are being able to select students that were born and who lived longer in those regions that are considered priorities, in small and middle sized municipalities, and which a majority are from socio-economic less privileged families. Regarding the intentions of professional career, a high percentage of students’ intents to be specialized in one of the big areas of medicine, both those in the first years, as the students in their last years of graduation. The specialty that was the largest choice in the first group of students was General Surgery, and they intended to work in middle complexity, and in the private and public specialized care. In the second group, Family and Community Medicine was the most chosen, and the Basic Care was the prioritized service. The teachers showed commitment and adaptive effort to the new curricular formats with the adoption of active teaching methodologies and interdisciplinarity implemented in the four courses in several levels. There is a great approach of professors and students to the Healthcare Services from the first years of the course, especially the Basic Healthcare in the municipalities where these courses are established. The courses prioritize health issues that are prevalent in the regional and local scenarios. It was only in one of the municipalities that received the new courses that the contract of integration betweenthe university and the service was totally formalized. The professors pointed out several challenges that need to be overcame for the potential axis Education is more effectively established, and several of these issues transcend the governability of the universities. They believe that there will be a significant change in the profile of these future professionals, with a new approach to the people, the communities, and their health issues. The final analysis of the axis Education of the Mais Medicos Program was structured under the view of the Policies Cycles Approach of Stephen Ball. It is highlighted that disputes in the context of influences are tensioning the program around two main positions that, in the political game often get mixed up. On one side, there are agencies that are representative of the medical category, and big economical groups that are interested in maintaining the market with full employment, in strengthening the supplementary healthcare, the private companies, insurance companies, and higher education institutions; this is why they were against the Mais Medicos Program. On the other side, there are groups that are interested in strengthening the Single Healthcare System, Primary Healthcare, and the consolidation of a qualified and valued medical career for this level of healthcare, and so support the changes proposed in the Education axis. Between these two positions, there are the physicians and the several factors that interfere in their future perspectives, in their work choices, and in their personal lives. These disputes had repercussion in the context of the production of texts, and in the context of the practice. The legal framework of the program has frailties that allow for the negotiation of commitments taken, severely compromising the structuring of new courses. Nevertheless, the power of the policy was shown in the micropolitical scenarios, in the selection of students, and in the quality of education, which are aligned with international references. This fact signals to positive changes in the profile of the graduating students of these institutions. It becomes important to consider the enormous challenges of the global and national political scenarios, which put in risk the objectives and the greatness of the program. The current government has announced a new program to substitute Mais Medicos, besides a new model of financing Primary Healthcare, compromising the financing and favouring privatization. More studies are necessary to contribute in the strengthening of Primary Healthcare as a work area, in consolidating Family and Community Medicine as a medical specialty, and in creating stimuli for the professors, and to regain the power of our public universities.