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

Brazil’s experiment to expand its medical workforce through private and public schools. 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Impacts and consequences of the balance of regulatory and market forces in resource- scarce settings Mário Scheffer, Paola Mosquera, Alex Cassenote, Barbara McPake, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5334074/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Mar, 2025 Read the published version in Globalization and Health → Version 1 posted 12 You are reading this latest preprint version 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 legislation to liberalise the medical education market and implement quotas to improve its supply of physicians – the Mais Médicos (More Doctors) Legislation (MML). 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 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. 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%). 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 and discuss the implications for similar countries. Private schools can be critical for expansion; but the data from Brazil suggest the private sector does little to address inequalities and cast doubt on the quality of the training offered. Physicians medical schools scaling-up policies health workforces health markets in LMICs. Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION AND BACKGROUND Increasing medical doctor density has been associated with improved health system performance, reduced burden of disease, and better health outcomes such as maternal mortality ratio, under-five mortality rate, infant mortality rate, and neonatal mortality rate[1]. Notwithstanding, for the World Health Organization the world is currently experiencing “a dangerous scarcity of health workers”[2], and doctors and healthcare workers “must urgently be trained and retained” [3]. Modelling studies estimated that in 2019 the world had 1.67 doctors per 1,000 population worldwide, whereas a density of at least 2.07 would be needed to achieve effective coverage of UHC [4], and 3.3/1,000 in 2030 to achieve the health related Sustainable Development Goals by the end of the decade [5]. A mix of recruitment and retention policies will be needed to achieve such ratios [6], but an expansion of health worker training capacity is certainly required to ensure a sufficient pool from which to recruit, particularly for those countries with the fastest growing economies and population [7]. Expanding national medical training in resource-scarce settings is complex, expensive, riddled with implementation challenges, and likely to bear a noticeable impact only in the longer term [8]. Scaling up government health financing has traditionally been considered the main modality for medical education expansion [9]; however, LMICs experiences in the last decade have raised concerns that rapid state expansion in medical training might be mired by implementation hurdles and put at risk the quality of education [10]. The existence of medical education markets has more recently been noticed, and private sector involvement in that market has been growing rapidly in a number of countries [11]. In 2010, the Lancet Commission on the Education of Health Professionals set out the guidelines for transforming medical education in the new century, recognising both the potential role of private financing as an additional source of investment in medical schools, but also concerns about quality and social purpose of privately owned schools [12]. In 2022 there were 3,986 operational medical schools worldwide, with a growing proportion of private colleges [13]. Although the private sector has been credited with contributing to the growth of supply [14], the rise of private for profit medical schools in lower-income countries is often viewed with suspicion, as for many, profit and educational motives are inherently antithetical [15]. On the other hand, studies from a high-income country such as Japan show that private medical schools offer a comparatively more favourable gender balance, as well as more leadership opportunities for female doctors [16]. In Brazil, the expansion of medical courses and placements has been driven by legislation and policies issued by the Federal Government in the last decade. The Mais Médicos (More Doctors) Law (MML) was introduced in 2013 with the stated objective to “…provide an answer to the urgent need to increase the number of doctors engaged with primary care training […] with a view to alleviate the historical scarcity of such professionals across the country” [17]. It introduced two key elements: (a) an emergency program to provide doctors in primary care to historically underserved municipalities (initially with Cuban doctors and, after 2019, primarily with Brazilian doctors); (b) the liberalisation of private undergraduate courses and student places. While the primary care doctors measures have received most of the attention [18,19], this article focuses on the second component of MML, and on its impact on the supply of doctors in Brazil. Since 2013, medical courses have been authorized through ad hoc legislation targeting private institutions and specific disadvantaged locations. Over the last two decades, successive Brazilian governments have implemented policies aimed at broadening access to higher education for socioeconomically underrepresented groups. This includes an increase in medical undergraduate student places in municipalities with lower physician-to-inhabitant ratios, primarily facilitated by federal universities. A parallel set of policies - The University for All Program (PROUNI) - has played a role by providing scholarships in private universities for poor students, covering different proportions of fees based on family income [20]. At the same time, public universities have gradually adjusted admission policies to enhance access for low-income, black, and indigenous students. In 2012, the Lei de Quotas federal law mandated that 50% of undergraduate placements in federal universities be reserved for students from public high schools, with a priority for those from low-income backgrounds, with disabilities, and self-identifying as ‘black’ or ‘indigenous’[21]. By 2023, there were 389 medical schools in the country – up from 222 in 2013 – the majority of which (268) of private nature [22]. Preliminary studies claim Brazil’s policies for scaling up of medical training has improved access to medical training and geographical distribution of the medical workforce [23,24]. METHODS Our methodological approach was to compare the evolution of medical workforce and medical students in the decades before and after the 2013 policies. Our analysis focussed particularly on medical students as: (a) those policies were intended to expand medical training capacity, and; (b) such impact would be lagged and felt on the medical workforce only 5-6 years later, when medical students finished their education. Data sources Data on physician workforce was extracted from the Brazilian Federal Medical Board (BFMB) registry December 2003, 2013, and 2023. Physician's specialty information comes from the Ministry of Education and the Brazilian Medical Association, which are the two legal issuers of specialist diplomas in Brazil. Disaggregation of this data allowed the study of the spatial distribution of doctors. The Medical Demography Study Group of the Medical School of the University of São Paulo has collected and analyzed such data since 2010 [25,26]. Information on medical courses and students was obtained from the “Undergraduate courses” section of the ‘Anísio Teixeira National Institute of Educational Studies and Investigations’ database (INEP), from 2013 to 2022, based on the 'name of the course' according to the International Standardized Classification of Education/Unesco. The 2019 National Student Attainment Exam (ENADE) dataset (e-MEC) was used to assess teaching quality across public and private medical schools. Such an exam is carried out in all Universities and Faculties in Brazil, is structured into a General Education component, which assesses general skills and knowledge, and a Specific Knowledge component, which evaluates the knowledge and skills expected for the professional profile. ENADE focusses on evaluating the quality of institutions rather than individual students, is not a national 'bar exam', and does not prevent medical students with poor performance from obtaining their diploma and subsequent medical licence. The ENADE dataset e-MEC was obtained from the Ministry of Education and Culture [27]. Data analysis Aggregate student data included the number of students enrolled each year; gender, self-declared race, secondary education, participation in minority reservation programs, student financing, and type of financing. To analyze the increasing trend of students and physicians, interrupted time-series (ITS) analysis was conducted using segmented linear regression, comparing two time periods considering the MML as the start of the intervention. Since the MML was implemented in October 2013, we considered the start of the intervention as 2014 for student numbers and 2020 for doctors’ numbers. Ordinary least-squares regression models with robust standard errors were run to estimate β-coefficients with 95% confidence intervals (CIs) to report the average annual change in the number of subjects during the preintervention period (slope of the outcome), the average number of subjects at the beginning of the intervention (compared with the counterfactual), and the difference in the average annual change in the number of subjects between pre-intervention and post-intervention periods (slope of the outcome). The Cumby-Huizinga statistic was used to test for autocorrelation of error terms in the regression models [28]. Being based on secondary analysis of already collected data, this project was deemed exempt from ethical approval by the ethics board of the faculty of medicine of the University of São Paulo. The medical demography and medical students databases were analysed through the Statistical Package for the Social Sciences (SPSS) version 26 for Windows (International Business Machines Corp, New York, USA), R-GUI version 3.5.3[29] for statistical analysis, and Microsoft Excel for Mac version 16.8. RESULTS Overall impact on the national workforce Our data show there has been a consistent growth of the medical workforce in Brazil in the last twenty years, both in absolute and in per capita terms; doctors headcount increased by 98.12%, going from 284,854 in 2003 to 564,363 in 2023. Although the workforce increased steadily each year since 2003, the largest increases were recorded recently, after 2020; the average annual rate of increase was 4.87% for the period 2020 to 2023, as compared to a rate of 4.0% for the previous period between 2003-2019. Slower annual growth was particularly noticeable between 2006 and 2010 (Fig.1). Source: Medical Demography, University of São Paulo 51.9% of practicing doctors in 2023 graduated from private medical schools, up from 36.8% in 2003 [26]. Despite Brazil’s population growth of the last decade, the increase in the medical workforce lifted the national doctor per population ratio from 1.42 per 1,000 population in 2003, to 1.90 in 2013, and 2.77 in 2023. All Brazil’s states saw an increase of doctors per capita, particularly those northern and Amazonian states like Maranhão, Amapá and Pará that used to have fewer than 1 doctor per 1,000 inhabitants. Whereas in 2003 as many as 12 states had less than one doctor per 1,000 inhabitants, in 2023 all states had surpassed that threshold. Paraiba state in Brazil’s underprivileged North-East, and Rio Grande do Sul and Santa Catarina from the rich South, experienced the largest increases, doubling their doctor density in the last ten years (Fig. 2 below). Source: Medical Demography, University of São Paulo Our analysis by municipality level shows that, between 2013 and 2023, doctor density improved across all types of municipalities, with least populated municipalities doubling their original doctor-to-population ratios (Table A1 in Annex). But in terms of absolute numbers, it was the most populated municipalities (>500,000) that benefitted the most from the influx of new doctors – 61% of the overall additional supply. Changes in location and profile of medical students Our data on medical school places show there were 245,501 students enrolled in 2022 (the latest available year of consolidated data), up from 111,198 in 2013, and 60,803 in 2003. At the latest count in 2022, there were 245,501 students enrolled in medical courses, 76.87% of whom were in private schools (up from 49.75% in 2003) - Figure 3. The overall 2003-2022 growth is largely driven by the increase of private medical school places after 2013, as private medical students went from 30,248 in 2003 to 70,755 in 2013, and 188,720 in 2022 – an increase of 166.72% over the last decade. Whereas the increase in doctors has been linear for the last 20 years, a substantial acceleration is visible after 2013 for medical students; their annual growth rate had reached 9.5% by 2022, while averaging 6.2% between 2003 and 2013. This followed a substantial slump in student intakes started in 2010 (Fig. A1 and A2 in annex). Interrupted time series analysis (Table 1) showed the number of physicians increased significantly every year prior to 2020 (when new students commencing after the legislation would graduate) by 13,593 doctors (95%CI: 12,493.5; 14,747.7, p<0.001). After the intervention, starting in 2020 there was a significant additional increase of 7,353 doctors above the expected rate (95%CI: 5,412.9; 9,293.5, p<0.001). As for medical student, prior to 2014 numbers increased every year by 5,703 (95%CI: 5,029.3; 6,377.7, p<0.001). In the first year of the intervention (2014), there was a non-significant decrease in the total number of students of 13,267 students (95%CI: -27,585.2; 1,050.9, p=0.067). <Insert: Table 1: Parameter estimates of the overall effect of the More Doctors Law (MML) on the annual number of students and physicians in Brazil from 2003 to 2023 The geographic distribution of enrolled medical students improved substantially in the 2003-2022 period; two decades ago, 50.9% of all students were studying in large state capital city areas whereas only 38.7% of them were in such areas in 2022 (Table A2 in annex). Comparatively, medical students in areas with between 100,000-300,000 inhabitants grew from 18.8% to 23.4%, and those in areas with fewer that 100,000 went from 6.1% to 14.6% of total. While the distribution of students across types of municipalities remained constant between 2003 and 2013, the largest increases of students in scarcely populated municipalities was recorded after 2013, particularly for areas with fewer than 300,000 inhabitants, that went from 27.57% to 37.49% in the last decade (Table A2 in annex). Most of the students in 2022 (62.5%) were still based in schools in municipalities with >300,000, but this has fallen from ten years earlier, when this proportion was 72.4%. In terms of their socio-demographic profile, despite gaps in the 2013 data, there are suggestions that diversity has increased over the last decade. Self-declared ‘White’ students still represent 68.7% of the 2022 cohort (it was 71.6% in 2013 although the majority of students failed to declare their race[1]). A substantial increase of self-declared ‘ Pardos’ (mixed-race) is noticeable in 2022 – 25.5%, up from 19.4%. All the other minority groups grew more than the average rate of increase of the overall student population (121%) (Table 2). Female students were 61.4% of the 2022 cohort, compared to 55.5% in 2013, while students from state secondary schools represent 31.9% of the most recent cohort, compared to 24.2% ten years earlier. When comparing students’ profiles across private and public medical schools in 2022, private schools reported more self-declared ‘White’ (74.1% Vs 51.8%), and Female (65.0% Vs 49.6%) students, predominantly from a private secondary school background (73.8% Vs 48.8%) (Table 2). Progress in relation to ethnic diversity has been quite modest. Overall, the proportion of those who declared a race declaring themselves white overall fell from 71.6% to 68.7% with a larger reduction in public schools (59.8% to 51.8%) than in private schools (79.4% to 74.1%). The proportion of ‘Minority Reservation Places’ programme (income and race minority quotas) among public medical schools was 38% in 2022 (up from 12.5% ten years earlier), but only 0.3% for private medical school students. Quality of public and private medical schools In terms of quality of teaching, when comparing test results between public and private schools, 78.5% of public schools achieved top average scores (level 4 and 5), compared with 30.9% of private ones in the 2019 national students’ attainment (ENADE) evaluation (p<0.001). Conversely, 18.7% of private schools received the lowest scores (levels 1 and 2), compared to 5.4% of public schools (p<0.001) (Fig.4). As per class size and tutor qualifications, 38.9% of students in public medical schools were taught in classes of more than 100 individuals, whereas the corresponding proportion for private medical schools was 80.4% (Figure A3 in annex). The student-to-faculty-member ratio in private medical schools in 2022 was considerably larger than in public ones (7.5 Vs 3.9). As a smaller proportion of the teaching staff in private medical schools had a doctorate degree, the ratio of students to faculty member with doctorate in such schools was over three times larger than in public schools. [1] In 2013, 52.5% of students failed to declare their race, while in 2022 only 11.7% did. DISCUSSION Our analysis indicates that Brazil’s MML succeeded in expanding the country’s medical workforce at a rate higher than would otherwise have occurred. Although the growth had started before 2013 [24], our medical demography evidence suggests that the MML policies accelerated the rate at which medical students are trained and incorporated into the workforce. The student data are most convincing on this point, and the analysis suggests they began to increase about a year after the legislation, which is a credible response lag. MML policies also regulated the growth that took place after 2013 to produce qualitative changes in geographical distribution and student diversity; however, results in this respect have been more mixed. Although a growing proportion of students have been trained in underprivileged locations and all municipalities now have at least one doctor per 1000 population, we show it is the richer urban municipalities that have benefited the most from the increased supply of doctors. Evidence from other studies aligns with this finding; the country-wide benefits of MML seem to have been undermined by the widespread attraction of doctors to non-priority areas and local substitution effects [30], and in São Paulo state, recently graduated primary care doctors are increasingly opting for short(er) tenure in urban hospitals in place of the rural primary care roles envisaged [31]. We acknowledge a few limitations in our analysis. First, the Mais Médicos Legislation is not a single homogeneous policy, but rather a sequence of diverse supply-side interventions implemented since 2013 and spanning across multiple years. As a result, it was difficult to pin-point the specific effect of such measures on the market for physicians. Secondly, despite our team’s decade-long effort to collate and consolidate physician data [26,32,33], some socio-demographic data and school enrolment data are still missing for physicians and medical students, particularly for older datasets; we recognise this has left some of our analysis incomplete. Finally, the power of our interrupted time series analysis for doctors may have been affected by the short time considered after the intervention (three years), and by possible confounders affecting the supply of doctors over the last twenty years [28]. Brazil is an upper middle-income country which experienced rapid economic growth between 2003 and 2013 (with GDP growing by nearly 50% over this decade) and much slower growth between 2013 and 2023 (with total GDP growing by less than 10% over the decade) [34]. This is important context for assessing the economic conditions of countries in which the market alone might be likely to drive an expansion of the medical workforce, and under which supportive policies might be able to do so. Other contextual factors are likely also to be important for governments planning to scale-up health workforces. Expanding medical school places will only result in expanding student numbers if there is pent up demand for medical education among high school graduates with adequate attainment levels to be able to cope with medical education [35]. Given the increased capacity in the private sector, that demand needs to be backed by willingness and ability to pay fees that have been set at roughly double the average per capita income in Brazil or other middle-income countries. Our data on students’ attainment and student-to-staff ratios suggest that quality of education in private medical schools in Brazil is lower than in public ones. This finding is consistent with some other literature on this topic from other large, economically emerging middle-income nations [36] [37], and raises concerns about the suitability of private colleges as a tool to rapidly expand health workforces where regulatory capacity is limited. Since alternative public-only approaches have not produced better results, continuing to support a mix of public and private sector policies while strengthening regulation, might represent the most promising strategy for the expansion of health workforces, despite these concerns [38]. Regulations need to better address the definition, implementation, and monitoring of quality standards of private medical schools, to steward the private sector towards public objectives, albeit the hard constraints of resources both financial and human that regulation cannot address [39]. Our analysis suggests that private schools have contributed marginally to improve diversity in Brazil’s medical workforce. Given the large tuition fees, it is hardly surprising that private schools mostly attract students from privileged backgrounds [40]. On the other hand, MML’s minority quotas implemented in Brazil’s public universities appear to have had more impact. If confirmed, we believe our findings make an important contribution to the current debate on affirmative action, racial diversity, and access to higher education in Brazil [41] and elsewhere to the extent that substantial private investment is open to only more privileged social groups everywhere [42]. The outcomes of the increasing numbers of medical graduates for the geographical distribution of medical workforce are also contingent on labour market conditions in situ . A number of those conditions determine whether new graduates will fill vacancies in primary care in more remote locations [43]. Evidence that returns are insufficient to motivate accepting roles in such locations from São Paolo State [31] is suggestive of what is probably the national situation. Policy will need to address improving terms and conditions in these roles for them to become the preferred choice for a sufficient number of graduates. This is likely to be a consideration in most countries considering the relevance of the Brazilian experience. CONCLUSIONS Expanding national medical workforces to increase population access to health services is a global preoccupation for governments in resources-constraints settings. However, few examples exist of successful public or private sector policies to carry out such scaling-up. We used evidence from original medical demography and medical students’ datasets from Brazil to analyse the supply of doctors in the decades before and after the introduction of its Mais Médicos Legislation , a set of policies aimed at liberalising the medical education market and implementing quotas to improve its supply of physicians. Our analysis suggests that Brazil’s policy approach has delivered a substantial overhaul of its medical workforce through a combination of public and private sector interventions, and that there might be scope to address workforce shortages using strategies similar to those that have been employed in Brazil. Nevertheless, there seem to be important caveats with respect to the quality and diversity implications of such heavy reliance on private initiative to expand training opportunities and take them up. All countries will have to consider how those caveats apply in context, and the trade-offs involved between quality, geographical distribution and equal opportunities on the one side, and numbers and availability on the other. Declarations Ethics approval and consent to participate. This paper is based on secondary data from Brazil’s Medical Demography collected over the last 20 years by the University of São Paulo, and therefore does not require ethics approval or consent to participate. Consent for publication. This paper does not contain any individual person’s data in any form, and therefore consent for publication was not sought. Availability of data and materials. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests. The authors declare that they have no competing interests Funding. The research at the basis of the present paper was supported by the UK Medical Research Council and Newton Fund (Grant Reference MR/R022747/1). The funder had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript. Authors' contributions. MS participated in the conceptualisation of the manuscript, in the data analysis, acquisition of funds, and revisions of the manuscript. PM participated in the analysis of data, and writing of the original draft. AC participated in the analysis of data, and writing of the original draft. BM contributed to conceptualisation of the work, in the analysis, draft of the original manuscript. GR participated in the conceptualisation of the work, in the analysis, and draft of the original manuscript. All authors read and approved the final manuscript. Acknowledgements. 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The privatization of medical education in Brazil: trends and challenges. Human Resources for Health. 2015;13:96. Scheffer MC, Pastor-Valero M, Cassenote AJF, Compañ Rosique AF. How many and which physicians? A comparative study of the evolution of the supply of physicians and specialist training in Brazil and Spain. Hum Resour Health. 2020;18:30. The World Bank. World Bank Open Data [Internet]. World Bank Open Data. 2024 [cited 2024 Sep 20]. Available from: https://data.worldbank.org McPake B, Maeda A, Araújo EC, Lemiere C, El Maghraby A, Cometto G. Why do health labour market forces matter? Bull World Health Organ. 2013;91:841–6. Ananthakrishnan N, Shanthi AK. Attempts at regulation of medical education by the MCI: issues of unethical and dubious practices for compliance by medical colleges and some possible solutions. Indian J Med Ethics. 2012;9:37–42. Shehnaz SI. Privatization of medical education in Asia. SE Asian Jnl Med Educ. 2011;5:18. Coveney L, Musoke D, Russo G. Do private health providers help achieve Universal Health Coverage? A scoping review of the evidence from low-income countries. Health Policy and Planning. 2023;38:1050–63. McPake B, Hanson K. Managing the public–private mix to achieve universal health coverage. The Lancet. 2016;388:622–30. Russo G, Cassenote AJF, Guilloux AGA, Scheffer MC. The role of private education in the selection of primary care careers in low and middle-income countries. Findings from a representative survey of medical residents in Brazil. Human Resources for Health. 2020;18:11. dos Santos PS, Becker KL, de Oliveira SV. Race-based affirmative action for higher education in Brazil: Impact assessment on performance, time, and delay in completion*. Review of Development Economics. 2023;27:247–67. Garces LM, Mickey-Pabello D. Racial Diversity in the Medical Profession: The Impact of Affirmative Action Bans on Underrepresented Student of Color Matriculation in Medical Schools. J Higher Educ. 2015;86:264–94. McPake B, Scott A, Edoka I. Analyzing Markets for Health Workers: Insights from Labor and Health Economics [Internet]. The World Bank; 2014 [cited 2023 Mar 27]. Available from: https://elibrary.worldbank.org/doi/abs/10.1596/978-1-4648-0224-9 Tables Table 1: Parameter estimates of the overall effect of the More Doctors Law (MML) on the annual number of students and physicians in Brazil from 2003 to 2023 (95% CI) Average annual change prior to onset of MML effects β1 p-value Additional average annual increase after MML β2 p-value Difference between average annual change before and after MML β3 p-value Linear trend after the onset of the effects of the MML β1+ β3 p-value Doctors (before and after 2020)* 13593.6 (12493.5; 14747.7) <0.001 7353.2 (5412.9; 9293.5) <0.001 12220.4 (8982.6; 15458.2) <0.001 25814.1 (23068.1; 28560.2) <0.001 Students (before and after 2013)* 5703.5 (5029.3; 6377.7) <0.001 -13267.1 (-27585.2; 1050.9) 0.067 10540.1 (8414.7; 12665.5) <0.001 16243.7 (14033.9 - 18453.4) <0.001 *Threshold years for the effects of MML . Table 2: Evolution of students’ socio-demographic profile in public and private medical schools Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterial.docx Cite Share Download PDF Status: Published Journal Publication published 28 Mar, 2025 Read the published version in Globalization and Health → Version 1 posted Editorial decision: Revision requested 28 Dec, 2024 Reviews received at journal 22 Dec, 2024 Reviewers agreed at journal 15 Dec, 2024 Reviewers agreed at journal 14 Dec, 2024 Reviews received at journal 13 Dec, 2024 Reviewers agreed at journal 11 Dec, 2024 Reviews received at journal 06 Dec, 2024 Reviewers agreed at journal 06 Dec, 2024 Reviewers invited by journal 26 Nov, 2024 Editor assigned by journal 29 Oct, 2024 Submission checks completed at journal 29 Oct, 2024 First submitted to journal 25 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Russo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYBADOSBmPABm8hCpxRhEkKYlsYFoLfIOvM8kf/yxSe+7dsbgAEONHYPBmQP4tRgeYDeT5m1Ly515Oweo5Vgyg8HZBgJaGtjYpBkbDuduAGthO8BgcJ6Aw0BagA47nG4A1vKPCC3yDGxsEjxshxPAWhjbDhB2mAEzG7M10C+GM2+nFRxI7EvmkSTkffn2NsabwBCT57udvPHBh292cnxnEgjYchjGApmdQExEysMdTsA5o2AUjIJRMIIBADNlQh+5F4KaAAAAAElFTkSuQmCC","orcid":"","institution":"The Wolfson Institute of Population Health, Queen Mary University of London","correspondingAuthor":true,"prefix":"","firstName":"Giuliano","middleName":"","lastName":"Russo","suffix":""}],"badges":[],"createdAt":"2024-10-25 17:53:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5334074/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5334074/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12992-025-01105-8","type":"published","date":"2025-03-28T15:57:22+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":68531721,"identity":"8fb2429b-7ff3-4760-90cc-e653cacbdf26","added_by":"auto","created_at":"2024-11-08 09:15:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":64075,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eEvolution of registered medical doctors 2003-2023 and respective annual growth rate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSource: Medical Demography, University of São Paulo\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5334074/v1/8f60fff7f343d34553fcccb8.png"},{"id":68531719,"identity":"5ddf4373-beda-4e2a-97ac-d98a8d1b1d0d","added_by":"auto","created_at":"2024-11-08 09:15:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":109783,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDoctors per population in Brazil’s states in 2003, 2013, and 2023\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSource: Medical Demography, University of São Paulo\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5334074/v1/a2a7ea07b5cb38970f73a4da.png"},{"id":68531722,"identity":"a251959f-c649-4646-9bd3-565b3a52acfd","added_by":"auto","created_at":"2024-11-08 09:15:55","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":42765,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBreak-down of evolution of medical students by public and private between 2003-2022\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData source: National Institute of Educational Studies and Investigations Anísio Teixeira, INEP (‘undergraduate courses’ unit of the Higher Education Census)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5334074/v1/0f17beec1329106bf59aefd7.png"},{"id":68532738,"identity":"92181441-9dab-4f60-b9ba-634207af4b0c","added_by":"auto","created_at":"2024-11-08 09:23:56","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":7359,"visible":true,"origin":"","legend":"\u003cp\u003eENADE test scores by type of medical school (2019)\u003c/p\u003e\n\u003cp\u003eSource: e-MEC. Score results for medical schools (93 public and 139 private)\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5334074/v1/35324518d95d475e25d56c02.png"},{"id":79604851,"identity":"065d9b98-61a2-407f-b294-1572d6afd800","added_by":"auto","created_at":"2025-03-31 16:07:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":895284,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5334074/v1/012d747f-eea9-4e48-aa6c-18fb4dbc59ab.pdf"},{"id":68531723,"identity":"d3114649-3dad-4a20-b25d-88fa0b98814a","added_by":"auto","created_at":"2024-11-08 09:15:55","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":183752,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-5334074/v1/c3a2b4a6851ce48866292f53.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"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","fulltext":[{"header":"INTRODUCTION AND BACKGROUND","content":"\u003cp\u003eIncreasing medical doctor density has been associated with improved health system performance, reduced burden of disease, and better health outcomes such as maternal mortality ratio, under-five mortality rate, infant mortality rate, and neonatal mortality rate[1]. Notwithstanding, for the World Health Organization the world is currently experiencing “a dangerous scarcity of health workers”[2], and doctors and healthcare workers “must urgently be trained and retained”\u0026nbsp;[3].\u003c/p\u003e\n\u003cp\u003eModelling studies estimated that in 2019 the world had 1.67 doctors per 1,000 population worldwide, whereas a density of at least 2.07 would be needed to achieve effective coverage of UHC\u0026nbsp;[4], and 3.3/1,000 in 2030 to achieve the health related Sustainable Development Goals by the end of the decade\u0026nbsp;[5]. A mix of recruitment and retention policies will be needed to achieve such ratios\u0026nbsp;[6], but an expansion of health worker training capacity is certainly required to ensure a sufficient pool from which to recruit, particularly for those countries with the fastest growing economies and population\u0026nbsp;[7].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExpanding national medical training in resource-scarce settings is complex, expensive, riddled with implementation challenges, and likely to bear a noticeable impact only in the longer term\u0026nbsp;[8]. Scaling up government health financing has traditionally been considered the main modality for medical education expansion\u0026nbsp;[9]; however, LMICs experiences in the last decade have raised concerns that rapid state expansion in medical training might be mired by implementation hurdles and put at risk the quality of education\u0026nbsp;[10]. The existence of medical education markets has more recently been noticed, and private sector involvement in that market has been growing rapidly in a number of countries\u0026nbsp;[11].\u003c/p\u003e\n\u003cp\u003eIn 2010, the Lancet Commission on the Education of Health Professionals set out the guidelines for transforming medical education in the new century, recognising both the potential role of private financing as an additional source of investment in medical schools, but also concerns about quality and social purpose of privately owned schools\u0026nbsp;[12]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn 2022 there were 3,986 operational medical schools worldwide, with a growing proportion of private colleges\u0026nbsp;[13]. Although the private sector has been credited with contributing to the growth of supply\u0026nbsp;[14], the rise of private for profit medical schools in lower-income countries is often viewed with suspicion, as for many, profit and educational motives are inherently antithetical\u0026nbsp;[15]. On the other hand, studies from a high-income country such as Japan show that private medical schools offer a comparatively more favourable gender balance, as well as more leadership opportunities for female doctors\u0026nbsp;[16].\u003c/p\u003e\n\u003cp\u003eIn Brazil, the expansion of medical courses and placements has been driven by legislation and policies issued by the Federal Government in the last decade. The \u003cem\u003eMais Médicos\u003c/em\u003e (More Doctors) Law (MML) was introduced in 2013 with the stated objective to “…provide an answer to the urgent need to increase the number of doctors engaged with primary care training […] with a view to alleviate the historical scarcity of such professionals across the country”\u0026nbsp;[17]. It introduced two key elements: (a) an emergency program to provide doctors in primary care to historically underserved municipalities (initially with Cuban doctors and, after 2019, primarily with Brazilian doctors); (b) the liberalisation of private undergraduate courses and student places.\u003c/p\u003e\n\u003cp\u003eWhile the primary care doctors measures have received most of the attention\u0026nbsp;[18,19], this article focuses on the second component of MML, and on its impact on the supply of doctors in Brazil. Since 2013, medical courses have been authorized through ad hoc legislation targeting private institutions and specific disadvantaged locations. Over the last two decades, successive Brazilian governments have implemented policies aimed at broadening access to higher education for socioeconomically underrepresented groups. This includes an increase in medical undergraduate student places in municipalities with lower physician-to-inhabitant ratios, primarily facilitated by federal universities. A parallel set of policies - The University for All Program (PROUNI) - has played a role by providing scholarships in private universities for poor students, covering different proportions of fees based on family income\u0026nbsp;[20].\u003c/p\u003e\n\u003cp\u003eAt the same time, public universities have gradually adjusted admission policies to enhance access for low-income, black, and indigenous students. In 2012, the \u003cem\u003eLei de Quotas\u003c/em\u003e federal law mandated that 50% of undergraduate placements in federal universities be reserved for students from public high schools, with a priority for those from low-income backgrounds, with disabilities, and self-identifying as ‘black’ or ‘indigenous’[21]. By 2023, there were 389 medical schools in the country – up from 222 in 2013 – the majority of which (268) of private nature [22]. Preliminary studies claim Brazil’s policies for scaling up of medical training has improved access to medical training and geographical distribution of the medical workforce [23,24].\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eOur methodological approach was to compare the evolution of medical workforce and medical students in the decades before and after the 2013 policies. Our analysis focussed particularly on medical students as: (a) those policies were intended to expand medical training capacity, and; (b) such impact would be lagged and felt on the medical workforce only 5-6 years later, when medical students finished their education.\u003c/p\u003e\n\u003ch2\u003eData sources\u003c/h2\u003e\n\u003cp\u003eData on physician workforce was extracted from the Brazilian Federal Medical Board (BFMB) registry December 2003, 2013, and 2023. Physician's specialty information comes from the Ministry of Education and the Brazilian Medical Association, which are the two legal issuers of specialist diplomas in Brazil. Disaggregation of this data allowed the study of the spatial distribution of doctors. The Medical Demography Study Group of the Medical School of the University of São Paulo has collected and analyzed such data since 2010\u0026nbsp;[25,26].\u003c/p\u003e\n\u003cp\u003eInformation on medical courses and students was obtained from the “Undergraduate courses” section of the ‘Anísio Teixeira National Institute of Educational Studies and Investigations’ database (INEP), from 2013 to 2022, based on the 'name of the course' according to the International Standardized Classification of Education/Unesco.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe 2019 National Student Attainment Exam (ENADE) dataset (e-MEC) was used to assess teaching quality across public and private medical schools. Such an exam is carried out in all Universities and Faculties in Brazil, is structured into a General Education component, which assesses general skills and knowledge, and a Specific Knowledge component, which evaluates the knowledge and skills expected for the professional profile.\u0026nbsp;ENADE focusses on evaluating the quality of institutions rather than individual students, is not a national 'bar exam', and does not prevent medical students with poor performance from obtaining their diploma and subsequent medical licence.\u0026nbsp;The ENADE dataset e-MEC was obtained from the Ministry of Education and Culture\u0026nbsp;[27].\u003c/p\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eAggregate student data included the number of students enrolled each year; gender, self-declared race, secondary education, participation in minority reservation programs,\u0026nbsp;student financing, and type of financing.\u003c/p\u003e\n\u003cp\u003eTo analyze the increasing trend of students and physicians, interrupted time-series (ITS) analysis was conducted using segmented linear regression, comparing two time periods considering the MML as the start of the intervention. Since the MML was implemented in October 2013, we considered the start of the intervention as 2014 for student numbers and 2020 for doctors’ numbers. Ordinary least-squares regression models\u0026nbsp;with robust standard errors were run to estimate β-coefficients with 95% confidence intervals (CIs) to report the average annual change in the number of subjects during the preintervention period (slope of the outcome), the average number of subjects at the beginning of the intervention (compared with the counterfactual), and the difference in the average annual change in the number of subjects between pre-intervention and post-intervention periods (slope of the outcome). The Cumby-Huizinga statistic was used to test for autocorrelation of error terms in the regression models\u0026nbsp;[28].\u003c/p\u003e\n\u003cp\u003eBeing based on secondary analysis of already collected data, this project was deemed exempt from ethical approval by the ethics board of the faculty of medicine of the University of São Paulo. The medical demography and medical students databases were analysed through the Statistical Package for the Social Sciences (SPSS) version 26 for Windows (International Business Machines Corp, New York, USA), R-GUI version 3.5.3[29] for statistical analysis, and Microsoft Excel for Mac version 16.8.\u0026nbsp;\u003c/p\u003e"},{"header":"RESULTS","content":"\u003ch2\u003eOverall impact on the national workforce\u003c/h2\u003e\n\u003cp\u003eOur data show there has been a consistent growth of the medical workforce in Brazil in the last twenty years, both in absolute and in per capita terms; doctors headcount increased by 98.12%, going from 284,854 in 2003 to 564,363 in 2023.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough the workforce increased steadily each year since 2003, the largest increases were recorded recently, after 2020; the average annual rate of increase was 4.87% for the period 2020 to 2023, as compared to a rate of 4.0% for the previous period between 2003-2019. Slower annual growth was particularly noticeable between 2006 and 2010 (Fig.1).\u003c/p\u003e\n\u003cp\u003e\u0026lt;Insert here: Figure\u0026nbsp;1: Evolution of registered medical doctors 2003-2023 and respective annual growth rate\u0026gt;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSource: Medical Demography, University of S\u0026atilde;o Paulo\u003c/p\u003e\n\u003cp\u003e51.9% of practicing doctors in 2023 graduated from private medical schools, up from 36.8% in 2003\u0026nbsp;[26]. Despite Brazil\u0026rsquo;s population growth of the last decade, the increase in the medical workforce lifted the national doctor per population ratio from 1.42 per 1,000 population in 2003, to 1.90 in 2013, and 2.77 in 2023.\u003c/p\u003e\n\u003cp\u003eAll Brazil\u0026rsquo;s states saw an increase of doctors per capita, particularly those northern and Amazonian states like Maranh\u0026atilde;o, Amap\u0026aacute; and Par\u0026aacute; that used to have fewer than 1 doctor per 1,000 inhabitants. Whereas in 2003 as many as 12 states had less than one doctor per 1,000 inhabitants, in 2023 all states had surpassed that threshold. Paraiba state in Brazil\u0026rsquo;s underprivileged North-East, and Rio Grande do Sul and Santa Catarina from the rich South, experienced the largest increases, doubling their doctor density in the last ten years (Fig. 2 below).\u003c/p\u003e\n\u003cp\u003e\u0026lt;Insert here: Figure\u0026nbsp;2: Doctors per population in Brazil\u0026rsquo;s states in 2003, 2013, and 2023 \u0026gt;\u003c/p\u003e\n\u003cp\u003eSource: Medical Demography, University of S\u0026atilde;o Paulo\u003c/p\u003e\n\u003cp\u003eOur analysis by municipality level shows that, between 2013 and 2023, doctor density improved across all types of municipalities, with least populated municipalities doubling their original doctor-to-population ratios (Table A1 in Annex). But in terms of absolute numbers, it was the most populated municipalities (\u0026gt;500,000) that benefitted the most from the influx of new doctors \u0026ndash; 61% of the overall additional supply.\u003c/p\u003e\n\u003ch2\u003eChanges in location and profile of medical students\u003c/h2\u003e\n\u003cp\u003eOur data on medical school places show there were 245,501 students enrolled in 2022 (the latest available year of consolidated data), up from 111,198 in 2013, and 60,803 in 2003. At the latest count in 2022, there were 245,501 students enrolled in medical courses, 76.87% of whom were in private schools (up from 49.75% in 2003) - Figure 3.\u003c/p\u003e\n\u003cp\u003e\u0026lt;Insert Figure 3: Break-down of evolution of medical students by public and private between 2003-2022 \u0026gt;\u003c/p\u003e\n\u003cp\u003eThe overall 2003-2022 growth is largely driven by the increase of private medical school places after 2013, as private medical students went from 30,248 in 2003 to 70,755 in 2013, and 188,720 in 2022 \u0026ndash; an increase of 166.72% over the last decade.\u003c/p\u003e\n\u003cp\u003eWhereas the increase in doctors has been linear for the last 20 years, a substantial acceleration is visible after 2013 for medical students; their annual growth rate had reached 9.5% by 2022, while averaging 6.2% between 2003 and 2013. This followed a substantial slump in student intakes started in 2010 (Fig. A1 and A2 in annex).\u003c/p\u003e\n\u003cp\u003eInterrupted time series analysis (Table 1) showed\u0026nbsp;the number of physicians increased significantly every year prior to 2020 (when new students commencing after the legislation would graduate) by 13,593 doctors (95%CI:\u0026nbsp;12,493.5; 14,747.7,\u0026nbsp;p\u0026lt;0.001). After\u0026nbsp;the\u0026nbsp;intervention, starting in 2020 there was a significant additional increase of 7,353 doctors above the expected rate (95%CI:\u0026nbsp;5,412.9; 9,293.5,\u0026nbsp;p\u0026lt;0.001). As for medical student, prior to 2014 numbers increased every year by 5,703 (95%CI:\u0026nbsp;5,029.3; 6,377.7,\u0026nbsp;p\u0026lt;0.001). In the first year of the intervention (2014),\u0026nbsp;there was a\u0026nbsp;non-significant decrease in the total number of students of 13,267 students (95%CI:\u0026nbsp;-27,585.2; 1,050.9,\u0026nbsp;p=0.067).\u003c/p\u003e\n\u003cp\u003e\u0026lt;Insert: Table 1: Parameter estimates of the overall effect of the More Doctors Law (MML) on the annual number of students and physicians in Brazil from 2003 to 2023\u003c/p\u003e\n\u003cp\u003eThe geographic distribution of enrolled medical students improved substantially in the 2003-2022 period; two decades ago, 50.9% of all students were studying in large state capital city areas whereas only 38.7% of them were in such areas in 2022 (Table A2 in annex). Comparatively, medical students in areas with between 100,000-300,000 inhabitants grew from 18.8% to 23.4%, and those in areas with fewer that 100,000 went from 6.1% to 14.6% of total.\u003c/p\u003e\n\u003cp\u003eWhile the distribution of students across types of municipalities remained constant between 2003 and 2013, the largest increases of students in scarcely populated municipalities was recorded after 2013, particularly for areas with fewer than 300,000 inhabitants, that went from 27.57% to 37.49% in the last decade (Table A2 in annex). Most of the students in 2022 (62.5%) were still based in schools in municipalities with \u0026gt;300,000, but this has fallen from ten years earlier, when this proportion was 72.4%.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn terms of their socio-demographic profile, despite gaps in the 2013 data, there are suggestions that diversity has increased over the last decade. Self-declared \u0026lsquo;White\u0026rsquo; students still represent 68.7% of the 2022 cohort (it was 71.6% in 2013 although the majority of students failed to declare their race[1]). A substantial increase of self-declared \u0026lsquo;\u003cem\u003ePardos\u0026rsquo;\u003c/em\u003e (mixed-race) is noticeable in 2022 \u0026ndash; 25.5%, up from 19.4%. All the other minority groups grew more than the average rate of increase of the overall student population (121%) (Table 2).\u003c/p\u003e\n\u003cp\u003e\u0026lt;Insert here: Table 2: Evolution of students\u0026rsquo; socio-demographic profile in public and private medical schools\u0026gt;\u003c/p\u003e\n\u003cp\u003eFemale students were 61.4% of the 2022 cohort, compared to 55.5% in 2013, while students from state secondary schools represent 31.9% of the most recent cohort, compared to 24.2% ten years earlier.\u003c/p\u003e\n\u003cp\u003eWhen comparing students\u0026rsquo; profiles across private and public medical schools in 2022, private schools reported more self-declared \u0026lsquo;White\u0026rsquo; (74.1% Vs 51.8%), and Female (65.0% Vs 49.6%) students, predominantly from a private secondary school background (73.8% Vs 48.8%) (Table 2). Progress in relation to ethnic diversity has been quite modest. Overall, the proportion of those who declared a race declaring themselves white overall fell from 71.6% to 68.7% with a larger reduction in public schools (59.8% to 51.8%) than in private schools (79.4% to 74.1%). The proportion of \u0026lsquo;Minority Reservation Places\u0026rsquo; programme (income and race minority quotas) among public medical schools was 38% in 2022 (up from 12.5% ten years earlier), but only 0.3% for private medical school students.\u003c/p\u003e\n\u003ch2\u003eQuality of public and private medical schools\u003c/h2\u003e\n\u003cp\u003eIn terms of quality of teaching, when comparing test results between public and private schools, 78.5% of public schools achieved top average scores (level 4 and 5), compared with 30.9% of private ones in the 2019 national students\u0026rsquo; attainment (ENADE) evaluation (p\u0026lt;0.001). Conversely, 18.7% of private schools received the lowest scores (levels 1 and 2), compared to 5.4% of public schools (p\u0026lt;0.001) (Fig.4).\u003c/p\u003e\n\u003cp\u003e\u0026lt;Insert here Figure 4: ENADE test scores by type of medical school (2019)\u0026gt;\u003c/p\u003e\n\u003cp\u003eAs per class size and tutor qualifications, 38.9% of students in public medical schools were taught in classes of more than 100 individuals, whereas the corresponding proportion for private medical schools was 80.4% (Figure A3 in annex).\u003c/p\u003e\n\u003cp\u003eThe student-to-faculty-member ratio in private medical schools in 2022 was considerably larger than in public ones (7.5 Vs 3.9). As a smaller proportion of the teaching staff in private medical schools had a doctorate degree, the ratio of students to faculty member with doctorate in such schools was over three times larger than in public schools.\u003c/p\u003e\n\u003cp\u003e[1] In 2013, 52.5% of students failed to declare their race, while in 2022 only 11.7% did.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOur analysis indicates that Brazil’s MML succeeded in expanding the country’s medical workforce at a rate higher than would otherwise have occurred. Although the growth had started before 2013\u0026nbsp;[24], our medical demography \u0026nbsp;evidence suggests that the MML policies accelerated the rate at which medical students are trained and incorporated into the workforce. The student data are most convincing on this point, and the analysis suggests they began to increase about a year after the legislation, which is a credible response lag.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMML policies also regulated the growth that took place after 2013 to produce qualitative changes in geographical distribution and student diversity; however, results in this respect have been more mixed. Although a growing proportion of students have been trained in underprivileged locations and all municipalities now have at least one doctor per 1000 population, we show it is the richer urban municipalities that have benefited the most from the increased supply of doctors. Evidence from other studies aligns with this finding; the country-wide benefits of MML seem to have been undermined by the widespread attraction of doctors to non-priority areas and local substitution effects\u0026nbsp;[30], and in São Paulo state, recently graduated primary care doctors are increasingly opting for short(er) tenure in urban hospitals in place of the rural primary care roles envisaged\u0026nbsp;[31].\u003c/p\u003e\n\u003cp\u003eWe acknowledge a few limitations in our analysis. First, the \u003cem\u003eMais Médicos\u003c/em\u003e Legislation is not a single homogeneous policy, but rather a sequence of diverse supply-side interventions implemented since 2013 and spanning across multiple years. As a result, it was difficult to pin-point the specific effect of such measures on the market for physicians. Secondly, despite our team’s decade-long effort to collate and consolidate physician data\u0026nbsp;[26,32,33], some socio-demographic data and school enrolment data are still missing for physicians and medical students, particularly for older datasets; we recognise this has left some of our analysis incomplete. Finally, the power of our interrupted time series analysis for doctors may have been affected by the short time considered after the intervention (three years), and by possible confounders affecting the supply of doctors over the last twenty years\u0026nbsp;[28].\u003c/p\u003e\n\u003cp\u003eBrazil is an upper middle-income country which experienced rapid economic growth between 2003 and 2013 (with GDP growing by nearly 50% over this decade) and much slower growth between 2013 and 2023 (with total GDP growing by less than 10% over the decade)\u0026nbsp;[34]. This is important context for assessing the economic conditions of countries in which the market alone might be likely to drive an expansion of the medical workforce, and under which supportive policies might be able to do so.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOther contextual factors are likely also to be important for governments planning to scale-up health workforces. Expanding medical school places will only result in expanding student numbers if there is pent up demand for medical education among high school graduates with adequate attainment levels to be able to cope with medical education\u0026nbsp;[35]. Given the increased capacity in the private sector, that demand needs to be backed by willingness and ability to pay fees that have been set at roughly double the average per capita income in Brazil or other middle-income countries.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur data on students’ attainment and student-to-staff ratios suggest that quality of education in private medical schools in Brazil is lower than in public ones. This finding is consistent with some other literature on this topic from other large, economically emerging middle-income nations\u0026nbsp;[36]\u0026nbsp;[37], and raises concerns about the suitability of private colleges as a tool to rapidly expand health workforces where regulatory capacity is limited. Since alternative public-only approaches have not produced better results, continuing to support a mix of public and private sector policies while strengthening regulation, might represent the most promising strategy for the expansion of health workforces, despite these concerns\u0026nbsp;[38]. Regulations need to better address the definition, implementation, and monitoring of quality standards of private medical schools, to steward the private sector towards public objectives, albeit the hard constraints of resources both financial and human that regulation cannot address\u0026nbsp;[39].\u003c/p\u003e\n\u003cp\u003eOur analysis suggests that private schools have contributed marginally to improve diversity in Brazil’s medical workforce. Given the large tuition fees, it is hardly surprising that private schools mostly attract students from privileged backgrounds\u0026nbsp;[40]. On the other hand, MML’s minority quotas implemented in Brazil’s public universities appear to have had more impact. If confirmed, we believe our findings make an important contribution to the current debate on affirmative action, racial diversity, and access to higher education in Brazil\u0026nbsp;[41]\u0026nbsp;and elsewhere to the extent that substantial private investment is open to only more privileged social groups everywhere\u0026nbsp;[42].\u003c/p\u003e\n\u003cp\u003eThe outcomes of the increasing numbers of medical graduates for the geographical distribution of medical workforce are also contingent on labour market conditions \u003cem\u003ein situ\u003c/em\u003e. A number of those conditions determine whether new graduates will fill vacancies in primary care in more remote locations [43]. Evidence that returns are insufficient to motivate accepting roles in such locations from São Paolo State [31] is suggestive of what is probably the national situation. Policy will need to address improving terms and conditions in these roles for them to become the preferred choice for a sufficient number of graduates. This is likely to be a consideration in most countries considering the relevance of the Brazilian experience.\u0026nbsp;\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eExpanding national medical workforces to increase population access to health services is a global preoccupation for governments in resources-constraints settings. However, few examples exist of successful public or private sector policies to carry out such scaling-up. We used evidence from original medical demography and medical students’ datasets from Brazil to analyse the supply of doctors in the decades before and after the introduction of its \u003cem\u003eMais Médicos Legislation\u003c/em\u003e, a set of policies aimed at liberalising the medical education market and implementing quotas to improve its supply of physicians.\u003c/p\u003e\n\u003cp\u003eOur analysis suggests that Brazil’s policy approach has delivered a substantial overhaul of its medical workforce through a combination of public and private sector interventions, and that there might be scope to address workforce shortages using strategies similar to those that have been employed in Brazil. Nevertheless, there seem to be important caveats with respect to the quality and diversity implications of such heavy reliance on private initiative to expand training opportunities and take them up. All countries will have to consider how those caveats apply in context, and the trade-offs involved between quality, geographical distribution and equal opportunities on the one side, and numbers and availability on the other.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate. This paper is based on secondary data from Brazil’s Medical Demography collected over the last 20 years by the University of São Paulo, and therefore does not require ethics approval or consent to participate.\u003c/p\u003e\n\u003cp\u003eConsent for publication. This paper does not contain any individual person’s data in any form, and therefore consent for publication was not sought.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests. The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eFunding. The research at the basis of the present paper was supported by the UK Medical Research Council and Newton Fund (Grant Reference MR/R022747/1). The funder had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003eAuthors' contributions. MS participated in the conceptualisation of the manuscript, in the data analysis, acquisition of funds, and revisions of the manuscript. PM participated in the analysis of data, and writing of the original draft. AC participated in the analysis of data, and writing of the original draft. BM contributed to conceptualisation of the work, in the analysis, draft of the original manuscript. GR participated in the conceptualisation of the work, in the analysis, and draft of the original manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements. The authors are indebted to Cristiane de Almeida for support of the data collection, and organisation of events related to this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eLiu J, Eggleston K. The Association between Health Workforce and Health Outcomes: A Cross-Country Econometric Study. Soc Indic Res. 2022;163:609\u0026ndash;32.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Global strategy on human resources for health: workforce 2030 [Internet]. Geneva: World Health Organization; 2016 [cited 2024 Feb 23]. Available from: https://iris.who.int/handle/10665/250368\u003c/li\u003e\n \u003cli\u003eAgyeman-Manu K, Ghebreyesus TA, Maait M, Rafila A, Tom L, Lima NT, et al. Prioritising the health and care workforce shortage: protect, invest, together. 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Race-based affirmative action for higher education in Brazil: Impact assessment on performance, time, and delay in completion*. Review of Development Economics. 2023;27:247\u0026ndash;67.\u003c/li\u003e\n \u003cli\u003eGarces LM, Mickey-Pabello D. Racial Diversity in the Medical Profession: The Impact of Affirmative Action Bans on Underrepresented Student of Color Matriculation in Medical Schools. J Higher Educ. 2015;86:264\u0026ndash;94.\u003c/li\u003e\n \u003cli\u003eMcPake B, Scott A, Edoka I. Analyzing Markets for Health Workers: Insights from Labor and Health Economics [Internet]. The World Bank; 2014 [cited 2023 Mar 27]. Available from: https://elibrary.worldbank.org/doi/abs/10.1596/978-1-4648-0224-9\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1: Parameter estimates of the overall effect of the More Doctors Law (MML) on the annual number of students and physicians in Brazil from 2003 to 2023 (95% CI)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAverage annual change prior to onset of MML \u0026nbsp; \u0026nbsp;effects \u0026beta;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAdditional average annual increase after MML \u0026beta;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDifference between average annual change before and after MML \u0026nbsp;\u0026beta;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLinear trend after the onset of the effects of the MML \u0026beta;1+ \u0026beta;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDoctors \u0026nbsp;(before and after 2020)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13593.6 (12493.5; 14747.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7353.2 (5412.9; 9293.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12220.4 (8982.6; 15458.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25814.1 (23068.1; 28560.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStudents (before and after 2013)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5703.5 (5029.3; 6377.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-13267.1 (-27585.2; 1050.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10540.1 (8414.7; 12665.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16243.7 (14033.9 - 18453.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Threshold years for the effects of MML .\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cspan lang=\"EN-GB\"\u003eTable 2: Evolution of students\u0026rsquo; socio-demographic profile in public and private medical schools\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cimg 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\"\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"EN-GB\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"globalization-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"glah","sideBox":"Learn more about [Globalization and Health](https://globalizationandhealth.biomedcentral.com/)","snPcode":"12992","submissionUrl":"https://submission.nature.com/new-submission/12992/3","title":"Globalization and Health","twitterHandle":"@GHJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Physicians, medical schools, scaling-up policies, health workforces, health markets in LMICs.","lastPublishedDoi":"10.21203/rs.3.rs-5334074/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5334074/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e. 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 legislation to liberalise the medical education market and implement quotas to improve its supply of physicians – the \u003cem\u003eMais Médicos\u003c/em\u003e (More Doctors) Legislation (MML). Such experience provides an insight for the global debate on the role of the private sector in medical education.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e. We draw from the analysis of unique medical demography datasets to assess the impact of those policies on 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings\u003c/strong\u003e. 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%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e. 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 and discuss the implications for similar countries. Private schools can be critical for expansion; but the data from Brazil suggest the private sector does little to address inequalities and cast doubt on the quality of the training offered.\u003c/p\u003e","manuscriptTitle":"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","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-08 09:15:51","doi":"10.21203/rs.3.rs-5334074/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-28T10:09:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-22T07:28:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"218326846665302370732243197934470618164","date":"2024-12-15T12:42:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"17202392275377278200720786536561595593","date":"2024-12-14T23:02:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-13T14:25:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138315716155407869871900195037447230978","date":"2024-12-11T05:50:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-06T13:38:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"23009815647092834728510525056457923407","date":"2024-12-06T09:58:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-26T13:58:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-29T06:06:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-29T06:04:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"Globalization and Health","date":"2024-10-25T17:45:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"globalization-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"glah","sideBox":"Learn more about [Globalization and Health](https://globalizationandhealth.biomedcentral.com/)","snPcode":"12992","submissionUrl":"https://submission.nature.com/new-submission/12992/3","title":"Globalization and Health","twitterHandle":"@GHJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9dae6878-b686-4af7-aff2-96d352c086a8","owner":[],"postedDate":"November 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-31T16:00:46+00:00","versionOfRecord":{"articleIdentity":"rs-5334074","link":"https://doi.org/10.1186/s12992-025-01105-8","journal":{"identity":"globalization-and-health","isVorOnly":false,"title":"Globalization and Health"},"publishedOn":"2025-03-28 15:57:22","publishedOnDateReadable":"March 28th, 2025"},"versionCreatedAt":"2024-11-08 09:15:51","video":"","vorDoi":"10.1186/s12992-025-01105-8","vorDoiUrl":"https://doi.org/10.1186/s12992-025-01105-8","workflowStages":[]},"version":"v1","identity":"rs-5334074","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5334074","identity":"rs-5334074","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}