Implementation of the More Doctors Program in Espírito Santo State, Brazil: logic model and proposed indicators

The study aimed to assess the implementation of the More Doctors Program (PMM in Portuguese) based on a case study of the Espírito Santo State, Brazil. The first stage involved analyzing the documents that launched the PMM, allowing the creation of a logic model. In the second stage, data on the PMM in Espírito Santo State were analyzed (2013-2016) based on population brackets, creating indicators for the proportion of physicians before and after the Program with the following parameters: unacceptable (0 to 0.99 physicians/1,000 inhabitants); acceptable (1 to 1.99); and desirable (2.0 or more). Data were analyzed with the Wilcoxon and Kruskal-Wallis non-parametric tests. The model included the size, inputs, activities, outputs, results, and impact of the PMM, orienting analysis of the Program’s implementation. Of all the physicians in the emergency supply to Espírito Santo State (432), the majority (63.8%) were cooperative exchange physicians (Cubans), while 31.2% were regional board-accredited Brazilians. The Brazilian and individual exchange physicians were allocated mainly in medium and large municipalities, while the Cubans were distributed more heterogeneously in municipalities of all population sizes and were thus more common in areas with greater social vulnerability and lower social capital. There was a significant increase in the number of physicians in Espírito Santo State, but the supply to the extremely poor population did not reach the desired level, presenting an unacceptable mean rate in municipalities with up to 10,000 inhabitants and an acceptable rate in municipalities in the other population brackets.本研究以巴西埃斯皮里图桑托州（Espírito Santo State）为案例研究对象，旨在评估“更多医生计划”（葡萄牙语缩写为PMM）的实施情况。第一阶段为分析启动该计划的正式文件，借此构建逻辑模型。第二阶段针对2013至2016年埃斯皮里图桑托州的PMM相关数据开展分析，以人口规模区间为划分依据，基于以下参数构建该计划实施前后的医师占比指标：不合格（每千居民拥有医师0至0.99名）、合格（每千居民1至1.99名）以及达标（每千居民2.0名及以上）。研究采用威尔科克森秩和检验（Wilcoxon）与克鲁斯卡尔-沃利斯秩和检验（Kruskal-Wallis）两种非参数检验方法对数据进行分析。该逻辑模型涵盖了PMM的规模、投入、活动、产出、结果与影响，为该计划的实施分析提供了指导框架。在为埃斯皮里图桑托州提供急诊医疗补给的全部432名医师中，绝大多数（63.8%）为古巴籍合作交流医师（Cubans），剩余31.2%为经地区医疗委员会认证的巴西籍医师。巴西籍医师与个人交流医师主要被分配至中等及大型城市，而古巴籍医师的分布在不同人口规模的城市中更为不均，因此在社会脆弱性更高、社会资本更低的地区更为常见。研究发现，埃斯皮里图桑托州的医师总量显著提升，但针对极端贫困人群的医疗供给仍未达到预期水平：人口不超过1万的城市的医师占比均值仍处于不合格区间，而其他人口规模区间的城市医师占比则处于合格区间。