Assessing the performance of beneficiary targeting in Brazil’s More Doctors Programme

Abstract

Many countries employ strategies that rest on the use of an explicitly defined set of criteria to identify underserved communities. Yet, we know relatively little about the performance of community-level targeting in large-scale health programmes. To address this gap, we examine the performance of community targeting in the More Doctors Programme (MDP). Our analysis covers all 5570 municipalities in the period between 2013 and 2017 using publicly available data. We first calculate the rate at which vulnerable municipalities enrolled in the MDP. Next, we consider two types of mistargeting: (1) proportion of vulnerable municipalities that did not have any MDP physicians (i.e. under-coverage municipalities) and (2) proportion of MDP enrolees that did not fit the vulnerability criteria (i.e. non-target municipalities). We found that almost 70% of vulnerable municipalities received at least one MDP physician between 2013 and 2017; whereas non-target municipalities constituted 33% of beneficiaries. Targeting performance improved over time. Non-target municipalities had the highest levels of socioeconomic development and greater physician availability. The poverty rate among under-coverage municipalities was almost six times that in non-target municipalities. Under-coverage municipalities had the lowest primary care physician availability. They were also smaller and more sparsely populated. We also found small differences in the political party alignments of mayors and the President between under-coverage and non-target municipalities. Our results suggest that using community-level targeting approaches in large-scale health programmes is a complex process. Programmes using these approaches may face substantial challenges in beneficiary targeting. Our results highlight that policymakers who consider using these approaches should carefully study various municipal characteristics that may influence the implementation process, including the level of socioeconomic development, health supply factors, population characteristics and political party alignments.

Brazil’s more doctors programme and infant health outcomes: a longitudinal analysis

“…Furthermore, the additional number of doctors provided may have been too small to substantially impact infant health outcomes. Secondly, there is evidence that the PMM doctors were allocated to non-priority municipalities likely limiting their effectiveness and potential to reduce IMR [ 14 , 15 ]. Many PMM doctors were allocated to areas with already low levels of IMR or where there were higher levels of non-PMM primary care doctors working.…”

“…This study found a lack of association between the PMM and infant health outcomes across strata when stratifying by municipal socio-economic characteristics including poverty and urbanisation. This suggests despite poor targeting of PMM doctors to priority municipalities [ 14 , 15 ], the relationship between the PMM and IMR was not substantially affected by municipal socio-economic factors other than infant mortality. This is generally supported by other studies which report no association between PMM and infant mortality in municipality subgroups of mother’s education, mother’s age and marital status [ 18 ].…”

“…These were: municipalities with 20% or more of the population living in extreme poverty; 100 municipalities with a population over 80,000 and the lowest income per capita; municipalities containing areas of extreme poverty; and municipalities with low human development index scores [ 14 ]. However, the prioritisation criteria was not adhered to well, and many non-criteria municipalities also received PMM doctors [ 14 , 15 ].…”

A Comparative Case Study: Does the Organization of Primary Health Care in Brazil and Turkey Contribute to Reducing Disparities in Access to Care?

“…Recently, the More Doctors Program (MDP), a large-scale PHC program that aimed at increasing investments for the FHS, attempted to address this challenge by recruiting domestic and foreign primary care physicians in low-resource communities. 76 Hone and colleagues (2020) found that the MDP led to improvements in physician availability, though this Program has been partially discontinued. 77 Turkey continues to confront similar disparities in the distribution of population health.…”

“…81 In congruence with these findings, similar community-level discrepancies were observed in the roll out of the MDP. 76 In Turkey, the MOH remains the main steward in the PHC system. Kringos and colleagues (2015) suggested that the clear delineation of rules and responsibilities in PHC delivery may have contributed to improvements in coordination of care and communication between the MOH and health authorities in provinces, and reductions in cross-provincial variation in the implementation of primary care policies.…”