MEDICAL WORKFORCE STRENGTHENING THROUGH PHYSICIAN PROVISION PROGRAMMES IN BRAZILIAN PRIMARY HEALTH CARE: A CROSS-SECTIONAL STUDY OF MUNICIPAL ADHERENCE, PARTICIPATION, AND FUNDING ARRANGEMENTS

Objective: This study aims to examine the adherence of Brazilian municipalities to federal and state-led physician provision programmes in Primary Health Care (PHC). It analyzes the participation and distribution of professionals within these programmes, as well as the involvement of federal and subnational entities in funding these positions. Methods: An ecological, cross-sectional, descriptive, and exploratory study was conducted in 2024, using Brazil’s 27 Federative Units as units of analysis. Secondary data from official sources were used to describe contextual factors, characteristics of provision programmes, and funding arrangements. Spearman’s rank correlation was applied to assess associations between physician participation and contextual variables. Results: A total of 81.9% of Brazilian municipalities had active vacancies in physician provision programmes, with the highest adherence rates observed in the North and Northeast regions. Nationally, approximately 40% of PHC teams are staffed by physicians linked to these programmes, with the North reaching nearly 60%. More than 96% of the positions are allocated to Family Health Teams. Regarding funding, over 60% of the posts are exclusively federally funded, while around 30% involve co-funding by municipalities. A negative correlation was observed between physician participation in provision programmes and both population density and the physician-to-population ratio, according to Spearman’s analysis. Conclusion: Provision programmes have played a critical role in sustaining PHC under Brazil’s Unified Health System (SUS), particularly in remote and underserved areas. However, challenges remain concerning dependency on federal programmes and regional disparities in physician distribution. The findings underscore the need for structured and coordinated policies across all levels of government to ensure equitable access to PHC nationwide. MEDICAL WORKFORCE STRENGTHENING THROUGH PHYSICIAN PROVISION PROGRAMMES IN BRAZILIAN PRIMARY HEALTH CARE: A CROSS-SECTIONAL STUDY OF MUNICIPAL ADHERENCE, PARTICIPATION, AND FUNDING ARRANGEMENTS PHYSICIAN PROVISION IN BRAZIL: MUNICIPAL ADHERENCE, PARTICIPATION AND FUNDING Bárbara Cássia de Santana Farias-Santos¹, Ana Paula Santana Coelho Almeida², Carolina Dutra Degli Esposti³, Thiago Dias Sarti⁴ ¹ Postgraduate Programme in Public Health, Federal University of Espírito Santo, Vitória, Brazil ² Department of Public Health, Federal University of Espírito Santo, Vitória, Brazil ³ Department of Public Health, Federal University of Espírito Santo, Vitória, Brazil ⁴ Department of Public Health, Federal University of Espírito Santo, Vitória, Brazil Corresponding author: Bárbara Cássia de Santana Farias-Santos¹ Postgraduate Programme in Public Health, Federal University of Espírito Santo Av. Marechal Campos, 1468 – Bonfim, Vitória - ES, Brazil, 29.047-105 E-mail: [email protected] ORCID: https://orcid.org/0000-0001-8418-9434 Ana Paula Santana Coelho Almeida² Department of Public Health, Federal University of Espírito Santo Av. Marechal Campos, 1468 – Bonfim, Vitória - ES, Brazil, 29.047-105 E-mail: [email protected] ORCID: https://orcid.org/0000-0001-5808-5818 Carolina Dutra Degli Esposti³ Department of Public Health, Federal University of Espírito Santo Av. Marechal Campos, 1468 – Bonfim, Vitória - ES, Brazil, 29.047-105 E-mail: [email protected] ORCID: https://orcid.org/0000-0001-8102-7771 Thiago Dias Sarti⁴ Department of Public Health, Federal University of Espírito Santo Av. Marechal Campos, 1468 – Bonfim, Vitória - ES, Brazil, 29.047-105 E-mail: [email protected] ORCID: https://orcid.org/0000-0002-1545-6276

The authors would like to thank the Fundação de Amparo à Pesquisa e Inovação do Espírito Santo (FAPES) for the doctoral scholarship granted to the first author, and the Postgraduate Programme in Public Health at the Federal University of Espírito Santo (UFES) for supporting the development of this study. Funding This study was partially supported by a doctoral scholarship granted to the first author by the Fundação de Amparo à Pesquisa e Inovação do Espírito Santo (FAPES), under the Public Call FAPES No. 14/2023 – PROCAP 2024. Competing interests The authors declare that they have no competing interests.

Objective: This study aims to examine the adherence of Brazilian municipalities to federal and state-led physician provision programmes in Primary Health Care (PHC). It analyzes the participation and distribution of professionals within these programmes, as well as the involvement of federal and subnational entities in funding these positions.

An ecological, cross-sectional, descriptive, and exploratory study was conducted in 2024, using Brazil’s 27 Federative Units as units of analysis. Secondary data from official sources were used to describe contextual factors, characteristics of provision programmes, and funding arrangements. Spearman’s rank correlation was applied to assess associations between physician participation and contextual variables.

A total of 81.9% of Brazilian municipalities had active vacancies in physician provision programmes, with the highest adherence rates observed in the North and Northeast regions. Nationally, approximately 40% of PHC teams are staffed by physicians linked to these programmes, with the North reaching nearly 60%. More than 96% of the positions are allocated to Family Health Teams. Regarding funding, over 60% of the posts are exclusively federally funded, while around 30% involve co-funding by municipalities. A negative correlation was observed between physician participation in provision programmes and both population density and the physician-to-population ratio, according to Spearman’s analysis.

Provision programmes have played a critical role in sustaining PHC under Brazil’s Unified Health System (SUS), particularly in remote and underserved areas. However, challenges remain concerning dependency on federal programmes and regional disparities in physician distribution. The findings underscore the need for structured and coordinated policies across all levels of government to ensure equitable access to PHC nationwide.

Primary Health Care, Health Workforce, Health Policy, Physicians Distribution Highlights • National coverage: 81.9% of municipalities have vacancies in medical programs. • Programs account for 40% of PHC teams; 96% in Family Health Teams. • Over 60% of positions are federally funded. • Coordinated policies are essential to ensure equitable access.

Scientific literature shows the importance of qualified Primary Health Care (PHC) for the effectiveness, efficiency and sustainability of health systems, especially in universal models such as the Unified Health System (SUS). 1–3 Since the 1990s, Brazil has opted to structure its public health system based on a community-oriented PHC, consolidated mainly through the Family Health Strategy (ESF). This strategy aims to organize, coordinate and offer comprehensive health care to the population, achieving wide coverage and making a significant contribution to reducing morbidity and mortality and health inequalities. 4,5 Despite these advances, structural and situational challenges persist that compromise universal access and comprehensive care. Among the main obstacles are chronic underfunding, poor management, a shortage of physicians in vulnerable areas, low professional qualifications and the limited problem-solving capacity of services, all of which contribute to overloading the secondary and tertiary levels of healthcare. 6,7 These difficulties are not exclusive to Brazil and have been widely documented in national and international studies since the 1960s. The scarcity and difficulty in retaining health professionals in rural, remote and socially vulnerable areas are recurring challenges faced by several countries. 8,9 In Brazil, since 1976 8, several initiatives have been implemented to reduce the shortage of professionals in PHC, most notably the More Doctors for Brazil Program (PMMB), created in 2013. Physician provision programmes in Brazil are public policy initiatives designed to recruit, deploy, and retain medical professionals in underserved and remote regions. These programmes aim to: (i) strengthen primary healthcare within the SUS, and (ii) reduce regional inequities in access to medical services, in alignment with the principles of equity and universality. The PMMB was structured around three main axes: emergency provision of physicians, reorganization of medical training and investment in the infrastructure of basic health units. 10 By September 2024, the program had approximately 22,000 physicians distributed in more than 80% of Brazilian municipalities. 11 Evaluations indicate positive results, such as an increase in care coverage and continuity of care and a reduction in referrals to specialized services. 12 As of 2019, changes in federal policy resulted in the gradual replacement of the PMMB by the Doctors for Brazil Program (PMpB), which aims to expand the provision of physicians in hard-to-reach areas and strengthen the training of specialists in Family and Community Medicine. 13 However, significant delays in its implementation, coupled with the temporary suspension of hiring under the PMMB, created uncertainty as to the continuity of care coverage, stimulating the adoption of alternative strategies. In this scenario, the state of Espírito Santo stood out by instituting a state policy aimed at providing and retaining professionals in PHC, with the creation, also in 2019, of the State PHC Qualification Program (Qualifica-APS) 14 which, developed in partnership with the municipalities, aims to expand coverage and increase the resolutiveness of PHC by linking continuing education, health surveillance, information technology and research. 15 In an unprecedented manner, this work compares federal programmes and a state programme, incorporating into the analysis underexplored dimensions, such as funding arrangements and federative governance. Studies carried out nationwide reveal that Brazilian municipalities have a significant adherence to federal programs to provide 12, especially in the North and Northeast regions, where there is a greater shortage of physicians. 16 These programs have also significantly influenced the composition of teams, increasing ESF coverage. 17 However, analyses comparing the different models in force, evaluating state initiatives, analyzing the proportion of PHC physicians linked to provision programs or detailing the role of subnational entities in funding vacancies remain limited. Given these gaps, this study aims to analyze the adherence of municipalities across Brazil’s Federative Units and the participation and distribution of physicians in primary health care provision and retention programs. In addition, it seeks to describe the participation of federal and subnational entities in the funding of the positions offered. Study Design This study is characterized as ecological, cross-sectional, descriptive, and exploratory, with the unit of analysis comprising the 27 Federative Units of Brazil, which include 26 states and the Federal District. Secondary data made available by official institutions was used (Figure 1), with the aim of verifying the adherence of the municipalities of the states to programs to provide and retain physicians in PHC, as well as describing the participation and distribution of medical professionals linked to these programs. To describe the event of interest in the study, the independent variables were contextual factors and the characteristics of the recruitment programs. The contextual variables included: population density, the Human Development Index (HDI), the Social Vulnerability Index (SVI), PHC coverage, private health insurance coverage, Bolsa Família program coverage and the physician-to-population ratio (per 1,000 inhabitants) (Figure 1). The variables related to the characteristics of the provision programmes included: municipal adherence to provision programmes; participation of medical professionals in these programmes; number of active PMMB professionals registered with the Brazilian Regional Council of Medicine (CRM); number of professionals in the exchange physician category; number of active PMpB professionals in the fellow and tutor categories; number of active professionals in the state-level Qualifica-APS programme; type of PHC team with a provision programme physician; and type of funding for medical posts (Figure 1). Statistical Analysis Municipal adherence refers to the formal enrolment of municipalities in physician provision programmes, carried out in response to public calls issued by managing authorities, such as the Ministry of Health or State Health Departments, depending on the programme. This adherence reflects the municipality’s institutional commitment to receiving health professionals through the programme and entails compliance with the technical and administrative requirements established in each initiative’s regulatory framework. These criteria vary according to the programme and may include: socioeconomic indicators (such as low per capita income or low Human Development Index scores), the existence of healthcare service gaps, Family Health Strategy coverage, historical difficulties in attracting and retaining physicians, and location in remote or socially vulnerable areas. Municipal adherence was estimated by calculating the ratio of municipalities with at least one medical vacancy in the programme to the total number of municipalities in the respective state. Professional participation refers to the effective allocation of physicians to municipalities through physician provision programmes, whether at the federal or state level. It represents the number of professionals who, after being approved through public selection processes (typically via calls for applications), occupied the available positions and began working in PHC teams. This variable distinguishes municipalities that merely adhered to the programme from those that actually incorporated physicians into their health service networks. Professional participation was calculated as the ratio between the number of physicians engaged in provision programmes and the total number of PHC teams in each Federative Unit, considering all team types. The result was expressed as a percentage. Physician profiles were classified according to the specific criteria of each programme. Under the PMMB, professionals were categorised into two groups: (i) CRM-Brazil – physicians with full registration from the Brazilian Federal Council of Medicine (CRM), who are eligible to work in any health facility nationwide without restrictions related to the More Doctors Programme; and (ii) Exchange physicians – professionals whose clinical practice is limited to activities within the exclusive scope of the Programme. 18 In the PMpB, participants are divided into: (i) Fellows – physicians who provide clinical care and participate in the training process; and (ii) Tutors – physicians specialised in Internal Medicine or Family and Community Medicine, responsible for the clinical supervision of fellows within Family Health Teams (eSF). The programme is implemented by the Brazilian Agency for Support to the Management of the Unified Health System (AgSUS), a federal public agency created in 2023 to coordinate and operationalise this national strategy. 13 In the state-level Qualifica-APS programme, there is a single category for medical professionals: “fellows”, as defined by the Internal Regulations of the Instituto Capixaba de Ensino, Pesquisa e Inovação em Saúde (ICEPi). 19 To assess the distribution of professionals by type of employment relationship, the ratio of active professionals by programme and employment category to the total number of professionals in training programmes was calculated. The distribution by PHC team type was analysed based on the proportion of active vacancies allocated to each team type, Family Health Teams (eSF), Street Clinic Teams (eCR), Multidisciplinary Indigenous Health Teams (eMSI), and Prison Primary Care Teams (eAPP), relative to the total number of active vacancies. Regarding the funding of positions, two modalities were identified: (i) Fully federal funding and (ii) Co-funding. In the exclusively federal funding model, all expenses (such as grants, indemnities, and operational costs of AGSUS) are covered by the Ministry of Health’s budget, constituting the standard model for federal programmes. Meanwhile, co-funding is a specific modality for expanding positions within the PMMB, based on voluntary municipal adherence. In this model, the municipality covers the professional’s grant, housing allowance, and meals, while the Ministry of Health bears the costs of other operational expenses. 20 Funding analysis was conducted by calculating the proportion of active vacancies by funding type in relation to the total number of active vacancies. To explore correlations between the participation of professionals in training programmes and contextual or programme-related variables, Spearman’s correlation test was applied. All analyses were conducted using states as the primary unit of analysis, with subsequent aggregation by geographic region and at the national level. Data collection was carried out between May and September 2024. Statistical analyses were performed using Stata 17 software, and maps were generated using Microsoft Excel®. Ethical considerations This study was conducted in accordance with the ethical principles of scientific research. Only secondary, non-identifiable data from official information systems were used. According to Resolution No. 510, of April 7, 2016, this type of study is exempt from submission for review by Research Ethics Committees.

Municipal Adherence and Physician Participation in Provision Programs Municipalities’ adherence to doctor provision programs shows significant variations between the regions and states of Brazil. Of Brazil’s 5,570 municipalities, 81.9% (4,558) have active vacancies in doctor provision programs. The North stands out with the highest percentage of adherence, with five of its states having 100% municipal adherence. In the Northeast and South, adherence rates are also high: the majority of northeastern states have more than 90% of participating municipalities, while the three states in the South have more than 80% municipal adherence (Figure 2). In the Midwest, the proportion of municipal adherence is 77.1%, and in the Southeast, 72.9%. In the latter, the state of Espírito Santo stands out as having the highest number in the region, with 98.7% of municipalities with active vacancies (Figure 2). As for participation in nationwide training programs, the data shows that around 40% of PHC teams are staffed by physicians linked to training programs, whether federal (PMMB and PMpB) or state, such as Qualifica-APS, implemented in Espírito Santo. The North again has the highest percentages, with almost 60% of PHC professionals linked to some kind of training program, and the states of Rondônia and Roraima exceeding 80% of teams with physicians from these programs (Figure 2). The Northeast (41.4%) and South (40.8%) have similar percentages. However, the state of Paraíba stands out, with 24.85% of professionals linked to the programs, the second lowest percentage among Brazilian states, behind only the Federal District. In the South, Paraná has the highest percentage, with 45.8% of PHC professionals linked to some kind of provision program (Figure 2). In the Southeast (35.7%) and Midwest (33.3%), the percentages are lower compared to the other regions. Even so, Espírito Santo stands out, with 86.6% of PHC medical professionals linked to some kind of recruitment and retention program, the highest percentage in the region (Figure 2). Distribution of Physicians by Provision Programme and State The distribution of physicians linked to training programmes varied considerably across Brazilian states, reflecting distinct regional patterns (Figure 3). For the PMMB, the highest proportions of physicians registered with the Brazilian Federal Council of Medicine (CRM-Brazil) were observed in the Northeast, particularly in Rio Grande do Norte (63.7%), Paraíba (60.1%), and the Federal District (60.3%). In contrast, the lowest proportions were recorded in Amazonas (19.4%), Roraima (21.9%), and Espírito Santo (21.8%). As also shown in Figure 3, exchange physicians under the PMMB were more prevalent in the North region, especially in Amazonas (75.4%) and Roraima (70.3%). The lowest proportions of these professionals were found in Paraíba (9.9%), Rio Grande do Norte (11.8%), and the Federal District (13.9%). With regard to the PMpB, the participation of fellows was more prominent in Northeastern states, notably in Sergipe (34.1%), Ceará (27.7%), and Bahia (27.3%). The lowest percentages were observed in Amazonas (4.7%), Roraima (6.2%), and Rio de Janeiro (6.3%). The proportion of PMpB tutors was consistently low across all states, ranging from 0.5% to 4.6%, with the highest values recorded in the Federal District (4.6%), Sergipe (4.5%), and Rio Grande do Norte (3.4%). Finally, the state-level Qualifica-APS programme, implemented exclusively in Espírito Santo, accounted for a substantial proportion of the PHC medical workforce in that state, representing 49.1% of participating physicians. Type of PHC Team and Funding Modalities for Medical Vacancies The ESF is the predominant model for physician allocation within Brazil’s provision programmes, accounting for 96.7% of all active vacancies, a consistent pattern observed across all regions of the country (Table 1). A comparative analysis of vacancy distribution by funding modality reveals marked regional disparities. As shown in Table 1, the North region presents the highest proportion of positions funded exclusively by the federal government (81.3%), followed by the Northeast (64.2%). Conversely, the South and Southeast regions exhibit a different pattern, characterised by a higher proportion of vacancies financed through co-funding arrangements between federal and subnational governments (35.2% and 39.2%, respectively). The Midwest displays an intermediate profile, with 77.9% of vacancies fully federally funded and 22.1% supported through co-funding mechanisms (Table 1). Correlation Between Contextual Factors and Participation in Provision Programmes Spearman correlation analyses were conducted to examine the relationship between the proportion of physicians participating in training programmes and contextual variables across Brazil’s federative units. The results revealed a statistically significant negative correlation between programme participation and both population density and the physician-to-population ratio (physicians per 1,000 inhabitants) (Figure 4). The remaining contextual variables, including the Human Development Index (HDI), Social Vulnerability Index (SVI), PHC coverage, private health insurance coverage, and Bolsa Família Programme coverage, did not demonstrate statistically significant correlations with participation in provision programmes (Figure 4). Figure 4 presents the scatter plots for the dependent variable against each contextual factor, including the estimated linear trend line. The Spearman correlation coefficient (ρ) and corresponding p-values are displayed on each graph.

The results of this study indicate broad uptake of medical provision programmes across Brazilian municipalities. At the national level, approximately 40% of PHC teams include physicians linked to these initiatives, a proportion that becomes even more significant within the ESF. In some states, this dependence reaches levels of nearly 90% of PHC doctors, underscoring the centrality of these programmes for the sustainability of care. The analysis of funding revealed that over 60% of positions are entirely funded by federal resources, while approximately 30% rely on co-funding arrangements between the Union and municipalities. An inverse correlation was observed between population density and the physician-to-population ratio with participation in the provision programmes. This finding corroborates the prioritisation logic guiding such initiatives, as their eligibility criteria, based on social and economic vulnerability indicators and health needs, 10,13(p13) were operationalised to direct professionals precisely to territories with historically greater scarcity and resource deprivation. However, the literature indicates that rigorous adherence to these criteria was not always observed throughout the implementation process. Studies suggest that the application of the rules was influenced by the political context and the actions of various interest groups, which at times prioritised their own agendas over the original technical objectives. 17 Moreover, this flexibility in parameters, driven by such pressures, may have compromised the effectiveness and reduced the expected impact of the programmes. 12,21 These findings underscore the essential role of provision programs in sustaining PHC within Brazil’s Unified Health System. The increase in federal investment in these initiatives responds to long-standing structural challenges in the system, including the chronic difficulty of retaining physicians in PHC and persistent imbalances in health care funding, which place a disproportionate burden on municipal budgets. Municipal dependence should not be interpreted merely as a weakness in local governance, but also as a manifestation of fiscal federalism in the country. The structure of the Brazilian fiscal regime in healthcare highlights the strong dependence of municipalities on the federal government. Although the 1988 Constitution established decentralisation as an organising principle of the SUS, the centralisation of tax revenue remains concentrated at the Union level, while the execution and financing of services increasingly fall to states and, especially, municipalities. This asymmetry results in near-total dependence on federal transfers for the majority of cities, particularly small-sized ones with low revenue-raising capacity. Thus, the fiscal autonomy of municipalities is limited, and their capacity for planning and investing in healthcare is contingent upon the volume, regularity, and distribution criteria of federal resources. 22 The literature shows that the expansion of medical provision for PHC is associated with improved access 17,23, reduction in morbidity and mortality 21,24 and reducing inequalities 25,26, especially in the context of the PMMB 12 . This study reinforces this evidence by demonstrating that provision programmes reach more vulnerable municipalities in terms of population density, indicating a greater presence of these initiatives in less populous and hard-to-reach regions. These programmes thus constitute fundamental pillars for guaranteeing healthcare in PHC. Studies highlight the difficulty these territories face in attracting physicians through conventional means, which justifies the targeted action of federal programmes. 23,26 The same pattern can be seen in the ratio between the number of physicians per thousand inhabitants and the higher proportion of professionals linked to the programs in municipalities with lower medical density. National studies, such as Fausto et al. 23 and Hone et al. 21, and a state survey conducted by Martinet al. 25 in Minas Gerais, corroborate these findings by showing the positive impact of the PMMB in increasing medical density in remote and vulnerable areas. In addition, the predominance of the ESF as the main arrangement for allocating physicians in the provision programs is in line with the objectives of the programs 10,13,14, the principles of the SUS and the National Primary Care Policy 5, which recognizes the ESF as a central element in expanding access, coordinating care and ensuring comprehensive health actions. While the positive impacts of these programs are evident, it is also necessary to consider their potential unintended consequences. Although they contribute to greater equity in resource distribution and improve access for vulnerable populations, there remains a risk that municipalities may become reliant on federally supplied professionals and funding. Such dependency can weaken local autonomy and discourage efforts to develop locally tailored strategies for team composition and financial management. Co-funding represents progress in fostering shared responsibility among federated entities; however, it warrants careful attention, as it may obscure underlying dependency dynamics. 27 Although these federal initiatives have contributed to expanding PHC coverage, adherence and the distribution of physicians still vary considerably between the states. The heterogeneity in the results indicates that, at a national level, the PMMB stands out in terms of the volume of active vacancies and has performed better than the PMpB in allocating professionals to priority areas. Despite the positive findings of Santos et al. 28 when analyzing the first results of the PMpB, this study identified a low proportion of physicians linked to it, attributed in part to the new political context and the relaunch of the PMMB in 2023. In addition, although the PMpB was established in 2019 with the aim of replacing the PMMB - prioritizing staffing in remote areas and specialized in-service training - it had limitations in its ability to attract professionals to hard-to-reach areas 26 . The lack of structuring measures in the areas of infrastructure and training, the requirement for a revalidated diploma in the calls for tenders, the low occupancy of vacancies and instability in management, especially during the government and institutional transition, have compromised its effectiveness, in contrast to the capillarity and scope observed in the PMMB at the height of its implementation. 4,29 An analysis of the funding types revealed a predominance of exclusive federal funding in the North and Northeast regions, while co-funding was more prevalent in the South and Southeast. This pattern suggests an effort to promote greater equity in resource allocation by channeling increased federal support to regions with greater socioeconomic vulnerabilities. This finding underscores the importance of understanding federative dynamics as a central element in the analysis of provision policies, demonstrating that the sustainability of these initiatives depends on the coordination between the Union, states, and municipalities, and not merely on the immediate availability of physicians. Seeking to respond to regional specificities in the distribution of physicians, state experiences have emerged as precursor strategies, as in the case of Bahia 8, and complementary to federal initiatives, as in Espírito Santo. These experiences show how arrangements between governments can strengthen the presence of professionals in Primary Care and diversify provision models. In Bahia, the creation of the Family Health State Foundation (FESF-SUS) in 2009 preceded the PMMB and sought to address long-standing challenges in PHC, such as low ESF coverage and difficulties in retaining physicians. The initiative aimed to establish an inter-federative public career pathway, focusing on reducing job fragmentation and promoting inter-municipal workforce management. However, its consolidation was hindered by institutional and operational challenges, including a lack of prior experience with this type of model. With the introduction of federal initiatives such as the Program for Valuing Primary Care Professionals (PROVAB) and, above all, the PMMB, which proved more attractive due to the absence of direct municipal costs and the provision of incentives for professionals, FESF-SUS lost momentum and ceased operating under its original model. 8 In Espírito Santo, the Qualifica-APS programme, coordinated by ICEPi, was established in 2019, coinciding with the launch of the PMpB, and remains active to this day. Its Provision and Fixation component has contributed to expanding access to healthcare and addressing inequalities in the distribution of health professionals. The state is notable for being the only federative unit with a state-level provision programme with significant participation, and for having 98.7% of its municipalities engaged in at least one provision programme, exceeding both the national and Southeast regional averages. Currently, 86.6% of PHC physicians in Espírito Santo are linked to some type of provision programme, nearly half of them through Qualifica-APS. Structured through bipartite cooperation with co-funding between the state and municipalities, the programme reinforces federative co-responsibility in sustaining provision efforts. In addition to physicians, it also includes other professional categories, according to local health system needs. 30 This study has several limitations. It relies on state-level aggregated indicators and adopts a cross-sectional design, which prevents causal inferences and fails to capture variations at the municipal level. Within the specific scope of the financial analysis, the Qualifica-APS programme was excluded from the comparison of funding arrangements. The reason for this is that, although the state programme is also co-funded, its model possesses a normative and operational structure so distinct from the federal programmes that it precludes a equitable metric comparison within the scope of this analysis. On the other hand, the originality of this study lies in its demonstration of how different funding arrangements, exclusively federal and co-funding, and the comparison between federal programmes and a state programme, Qualifica-APS, influence the sustainability of provision policies in Brazil.

This study contributes to the understanding of the implementation of physician provision and retention programmes in Brazilian PHC by analysing, in an unprecedented manner, municipal uptake, professional distribution, and funding modalities, with emphasis on the comparison between federal initiatives and the state programme Qualifica-APS. The results demonstrate that such programmes have played a fundamental role in expanding the medical workforce and mitigating regional inequalities in PHC. The experience of Espírito Santo with Qualifica-APS highlights the potential of subnational innovations to complement and diversify national provision strategies. Nevertheless, the findings also reveal persistent challenges, such as the high dependence of municipalities on federal programmes and the significant disparities in financial contributions from subnational entities. These factors underscore the imperative need for structured and permanently coordinated policies among federal, state, and municipal levels to ensure equitable access and long-term sustainability of primary health care across the national territory. REFERÊNCIAS 1. Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. Milbank Q . 2005;83(3):457-502. doi:10.1111/j.1468-0009.2005.00409.x2. Macinko J, Mendonça CS. Estratégia Saúde da Família, um forte modelo de Atenção Primária à Saúde que traz resultados. Saúde Em Debate . 2018;42:18-37. doi:10.1590/0103-11042018S1023. Tasca R, Massuda A, Mendes W, Buchweitz C, Harzheim E. Recomendações para o fortalecimento da atenção primária à saúde no Brasil. Rev Panam Salud Publica . 2020;44(4). doi:10.26633/RPSP.2020.44. Giovanella L, Franco CM, Almeida PFD. Política Nacional de Atenção Básica: para onde vamos? Ciênc Saúde Coletiva . 2020;25(4):1475-1482. doi:10.1590/1413-81232020254.018420205. Brasil. 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Trab Educ E Saúde . 2020;18(2):e00270101. doi:10.1590/1981-7746-sol0026928. Santos CMJD, Andrade SZDD, Wollmann L, et al. Doctors for Brazil Program: first results. Ciênc Saúde Coletiva . 2023;28(11):3273-3279. doi:10.1590/1413-812320232811.00072023en29. Anderson MIP. Médicos pelo Brasil e as políticas de saúde para a Estratégia Saúde da Família de 1994 a 2019: caminhos e descaminhos da Atenção Primária no Brasil. Rev Bras Med Fam E Comunidade . 2019;14(41):2180. doi:10.5712/rbmfc14(41)218030. Espírito Santo. Instituto Capixaba de Ensino, Pesquisa e Inovação em Saúde - ICEPi. Documentos - Componente de Provimento. Accessed April 30, 2025. https://icepi.es.gov.br/provimento-e-fixacao-de-profissionais Tables Table 1. Occupancy, team type, and funding sources in federal physician provision programmes by Federative Unit, Brazil. | filled vacancies | active vacancies eSF | active vacancies eMSI | active vacancies eCR | active vacancies eAPP | Federal | Co-funding | | | Brazil | 84.6 | 96.8 | 2.5 | 0.4 | 0.3 | 66.6 | 30.0 | | North | 85.5 | 90.1 | 9.5 | 0.2 | 0.1 | 81.3 | 18.7 | | RO | 85.5 | 93.8 | 6.0 | 0.0 | 0.2 | 77.0 | 23.0 | | AC | 88.0 | 86.8 | 12.8 | 0.4 | 0.0 | 90.9 | 9.1 | | AM | 88.1 | 84.1 | 15.6 | 0.1 | 0.0 | 84.1 | 15.9 | | RR | 81.6 | 73.1 | 26.3 | 0.0 | 0.5 | 93.9 | 6.1 | | PA | 84.2 | 96.2 | 3.5 | 0.2 | 0.1 | 79.9 | 20.1 | | AP | 86.0 | 92.8 | 6.4 | 0.4 | 0.4 | 72.0 | 28.0 | | TO | 86.2 | 94.6 | 4.7 | 0.7 | 0.0 | 69.0 | 31.0 | | Northeast | 85.8 | 97.8 | 1.5 | 0.2 | 0.4 | 64.2 | 25.5 | | MA | 85.7 | 96.5 | 3.4 | 0.0 | 0.1 | 82.6 | 17.4 | | PI | 83.3 | 99.6 | 0.0 | 0.2 | 0.2 | 77.6 | 22.4 | | CE | 83.1 | 98.5 | 1.3 | 0.1 | 0.1 | 82.0 | 18.0 | | RN | 83.0 | 98.8 | 0.0 | 0.5 | 0.7 | 60.5 | 39.5 | | PB | 81.2 | 95.6 | 2.9 | 1.0 | 0.6 | 82.7 | 17.3 | | PE | 90.4 | 97.3 | 1.1 | 0.2 | 1.4 | 4.1 | 41.4 | | AL | 79.9 | 95.1 | 3.4 | 1.3 | 0.3 | 72.4 | 27.6 | | SE | 87.0 | 99.7 | 0.0 | 0.0 | 0.3 | 77.1 | 22.9 | | BA | 87.4 | 98.4 | 1.3 | 0.2 | 0.1 | 77.3 | 22.7 | | Southeast | 84.4 | 98.8 | 0.2 | 0.6 | 0.4 | 60.8 | 39.2 | | MG | 83.2 | 98.4 | 0.8 | 0.5 | 0.3 | 56.4 | 43.6 | | ES a | 85.4 | 99.1 | 0.0 | 0.9 | 0.0 | 80.1 | 19.9 | | RJ | 88.3 | 97.9 | 0.0 | 1.0 | 1.1 | 48.3 | 51.7 | | SP | 83.5 | 99.5 | 0.0 | 0.4 | 0.1 | 65.5 | 34.5 | | South | 81.6 | 98.1 | 1.2 | 0.3 | 0.3 | 64.8 | 35.2 | | PR | 83.6 | 98.1 | 1.5 | 0.3 | 0.2 | 58.8 | 41.2 | | SC | 79.4 | 96.3 | 3.0 | 0.4 | 0.4 | 56.6 | 43.4 | | RS | 80.7 | 99.2 | 0.0 | 0.4 | 0.4 | 75.8 | 24.2 | | Midwest | 85.1 | 93.1 | 5.7 | 0.5 | 0.6 | 77.9 | 22.1 | | MS | 88.6 | 87.6 | 10.5 | 0.5 | 1.4 | 70.3 | 29.7 | | MT | 79.6 | 84.5 | 14.8 | 0.4 | 0.2 | 73.2 | 26.8 | | GO | 86.2 | 99.6 | 0.0 | 0.4 | 0.0 | 83.0 | 17.0 | | DF | 86.1 | 95.4 | 0.0 | 1.7 | 2.9 | 81.5 | 18.5 | a State-level provision data not included. eSF: Family Health Teams; eCR: Street Clinic Teams; eMSI: Multidisciplinary Indigenous Health Teams; eAPP: Prison Primary Care Teams. Source: Monitoring Panel of Physician Provision Programmes – Brazilian Ministry of Health, 2024. Figure legends Figure 1. Study variables: definitions and data sources Figure 2. Municipal adherence and professional participation in provision programs by Federative Unit. Brazil, 2024. Figure 3. Proportion of physicians linked to different provision programs in PHC by Federative Unit. Brazil, 2024. Figure 4. Correlation between physician participation in provision programs and contextual variables, by Federative Unit. Brazil, 2024. Information & Authors Information Version history Copyright This work is licensed under a Non Exclusive No Reuse License.

Authors Metrics & Citations Metrics Article Usage 166views 119downloads Citations Download citation Bárbara Cássia de Santana Farias-Santos, Ana Paula Santana Coelho Almeida, Carolina Dutra Degli Esposti, et al. MEDICAL WORKFORCE STRENGTHENING THROUGH PHYSICIAN PROVISION PROGRAMMES IN BRAZILIAN PRIMARY HEALTH CARE: A CROSS-SECTIONAL STUDY OF MUNICIPAL ADHERENCE, PARTICIPATION, AND FUNDING ARRANGEMENTS. Authorea. 10 October 2025. DOI: https://doi.org/10.22541/au.176006613.34167205/v1 DOI: https://doi.org/10.22541/au.176006613.34167205/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu.