Health System and
Medical Education in Brazil
Milton A. Martins
Professor of Medicine
University of Sao Paulo Medical School
Overview
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Something about Brazil
Health System
Physicians: number and distribution
Medical Education
Training of Specialists
Countries by Area (Km2)
1 Russia
17,098,242
2 Canada
9,984,670
3 China
9,572,900
4 United States
9,526,468
5 Brazil
8,515,767
6 Australia
7,692,024
Countries by Population
1
China
1,366,210,000
2
India
1,248,060,000
3
United States
318,577,000
4
Indonesia
252,164,800
5
Brazil
203,010,000
6
Pakistan
188,020,000
Countries by Gross Domestic Product
(millions of US dollars)
1
2
3
4
5
6
7
8
United States
China
Japan
Germany
France
United Kingdom
Brazil
Russia
16,244,600
8,358,400
5,960,180
3,425,956
2,611,221
2,471,600
2,254,109
2,029,812
But....
• Gross National Income per Capita
• Brazil ranks 52nd (U$ 11,630)
• And
• Human Development Index (HDI)
• Brazil ranks 79th
Brazil
Sao Paulo – Metropolitan Area
• Total area – 8,500 Km2
• Urban area – 2,200 Km2
• 19,822,572 inhabitants (2011)
Sao Paulo
Brazil: Health Challenges of Developed
and Developing World
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Burden of diseases include
Aging of population
Chronic diseases (cardiovascular and cancer)
Urban violence and motor vehicle accidents
Infectious diseases, old and new
Mental health
Brazil: Health Challenges of Developed
and Developing World
• We have very good public organ transplantation
system, comprehensive care of people who live
with HIV/AIDS and immunization coverage.
• In contrast, we will not be able to reach the
millennium development goal of reducing
maternal mortality.
• We have not been able to eradicate congenital
syphilis and have a high prevalence of Hansen’s
disease.
Brazilian Health System (1988)
• Since 1988, Brazil has developed a dynamic, complex
health system (the Unified Health System, SUS), which
is based on the principles of health as a citizen’s right
and the state’s duty.
• The SUS aims to provide comprehensive, universal
preventive and curative care through decentralized
management and provision of health services and
promotes community participation at all administrative
levels.
Brazilian Health System (1988)
• Implementation of SUS has been complicated by state
support for the private sector, the concentration of health
services in more developed regions, and chronic
underfunding.
• Brazil invests less than 4% of his gross national product
in the public health system.
Primary Care in Brazil
• The expansion of primary care has been achieved
mainly through the creation of the Program of Family
Health (Programa de Saúde da Família – PSF)
• PSF works through family health-care teams, which are
generally composed of one doctor, one nurse, one
auxiliary nurse and four to six community health workers,
and, since 2004, oral health teams. Each team takes
care of 600-1000 families.
• There are about 33,000 family health care teams,
reaching about 100 million people.
Physicians/1000 population
WHO regions
African Region
Region of the Americas
South-East Asia Region
European Region
Eastern Mediterranean Region
Western Pacific Region
Brazil
0.25
2.04
0.55
3.33
1.08
1.52
1.76
World Health Statistics 2013 (WHO)
Physicians/1000 population
Income Groups
Low income
Lower middle income
Upper middle income
High income
Brazil
0.51
0.78
1.78
2.71
1.76
World Health Statistics 2013 (WHO)
Brazil: Unequal Distribution of
Physicians
• Total number does not meet society’s needs
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Regions of the country
Large and small cities
Central and peripheral areas of large cities
Public and private sectors of the health system
Brazil: Unequal Distribution of Physicians
(Physicians/1000 population)
State
Maranhão
Pará
Acre
Piauí
0.64
0.80
0.92
0.94
State
Distrito Federal
Rio de Janeiro
São Paulo
3.83
3.52
2.50
Rio Grande do Sul
2.31
Medical Education in Brazil
• Medical course in Brazil is a 6-year program, usually with
two years of basic sciences, two years of clinical
sciences and two years of clerkships (internship).
• Professional education has not kept pace with the
challenges of the health systems in the world.
• This is the same in Brazil, although there has been a
substantial effort to change education of health
professions to meet the society needs.
Medical Education Guidelines in Brazil
• The guidelines for medical education established in 2001
define that medical schools must give a generalist
formation and that the major determinant of the curricula
in medical schools must be the health needs of the
population and the training of medical students must be
in all levels of the health system.
• Almost all medical schools of Brazil developed programs
to reorient their curricula to shift training from tertiary
hospitals to clinics and communities.
Medical Education Guidelines in Brazil
• The new guidelines for medical education published this
year by the Ministry of Education state that at least 30%
of the last years of medical education (internship) must
be composed of primary care and emergency care in the
Brazilian Heath System (SUS).
Increase in the Number of Medical
Schools in Brazil
• In the last years, there has been a substantial increase
in the number of Medical Schools in Brazil, mainly of
private schools.
• Both the Brazilian Medical Association and the Brazilian
Association of Medical Education oppose this increase.
• We believe that there are enough Medical Schools in
Brazil.
• There are also concerns about the quality of many of
these new Medical schools.
Medical Schools in Brazil
180
160
140
120
100
80
60
40
20
0
18
08
19
00
19
50
19
60
19
70
19
80
19
90
20
00
20
10
Number of Medical Schools
200
Year of opening
First Year Medical Students in Brazil
22000
Number of students
20000
18000
16000
14000
12000
10000
8000
6000
1990
1995
2000
Year
2005
2010
2015
Percentage of physicians that live in the
state of Brazil where they went to
Medical School (Seixas et al)
0 to 21%
0
21 to 41%
4
41 to 61%
7
61 to 81%
12
81 to 100% 1
Percentage of physicians that live in
the state of Brazil where they went to
Medical Residency (Seixas et al)
0 to 21%
0
21 to 41%
0
41 to 61%
1
61 to 81%
6
81 to 100%
16
Medical Residency in Brazil
• Medical Residency is not mandatory to work as a
physician in Brazil.
• In the last years, there has been a substantial increase
in the number of Medical Residency Programs in Brazil.
• There are about 2,000 more graduates in Medical
School than available positions for Residency.
• According to a recently approved law (2013), there will
be enough positions of Residency for all graduates from
Medical School by 2019.
• This increase will be mainly in Residency in Family
Medicine (Family and Community Medicine in Brazil).
Number of Positions Available for
Graduates in Medical Schools
Internal Medicine
2,620
General Surgery
1,830
Pediatrics
1,743
Family and Community Medicine
1,260
Gynecology and Obstetrics
1,144
Orthopedics
894
Anesthesiology
887
Psychiatry
524
Radiology
496
Ophthalmology
460
Dermatology
237
Otorhinolaryngology
233
Total
13,542
Residency in Surgery in Brazil
• Two years of General Surgery.
• The majority of residents decide to go to a second
Residency, in a subspecialty (Plastic Surgery, Urology,
Vascular Surgery, Cardiac Surgery, Thoracic Surgery,
Abdominal Surgery...)(2-3 more years).
• Most surgeons believe that two years of training are not
sufficient for a general surgeon.
• There are a few programs of General Surgery of 4 years,
in some Academic Health Centers.
Thank you for your attention