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Addressing inequalities in medical workforce distribution: evidence from a quasi-experimental study in Brazil
  1. Elisa Maria Maffioli1,
  2. Thiago Augusto Hernandes Rocha2,
  3. Gabriel Vivas3,
  4. Carlos Rosales2,
  5. Catherine Staton4,
  6. Joao Ricardo Nickenig Vissoci5
  1. 1 Health Management and Policy, University of Michigan, Ann Arbor, Michigan, USA
  2. 2 Pan American Health Organization Brazil, Brasilia, Brazil
  3. 3 Pan American Health Organization Brazil, Nassau, Bahamas
  4. 4 Duke Global Health Institute, Duke University, Durham, North Carolina, USA
  5. 5 Duke Emergency Medicine, Duke University Medical Center, Durham, NC, United States
  1. Correspondence to Professor Elisa Maria Maffioli; elisamaf{at}


Background Brazil faces huge health inequality challenges since not all municipalities have access to primary care physicians. The More Doctors Programme (MDP), which started in 2013, was born out of this recognition, providing more than 18 000 doctors in the first few years. However, the programme faced a restructuring at the end of 2018.

Methods We construct a panel municipality-level data between 2008 and 2017 for 5570 municipalities in Brazil. We employ a difference-in-differences empirical approach, combined with propensity score matching, to study the impacts of the programme on hospitalisations for ambulatory care sensitive conditions and its costs. We explore heterogeneous impacts by age of the patients, type of admissions, and municipalities that were given priority.

Findings The MDP reduced ambulatory admissions by 2.9 per cent (p value <0.10) and the costs by 3.7 per cent (p value <0.01) over the mean. The reduction was driven by infectious gastroenteritis, bacterial pneumonias, asthma, kidney and urinary infections, and pelvic inflammatory disease. The results held on the subsample of municipalities targeted by the programme. By comparing the benefits of the programme from the reduction in the costs of ambulatory admissions to the total financial costs of the MDP, the impacts allowed the government to save at least BRL 27.88 (US$ 6.9 million) between 2014 and 2017.

Conclusion Addressing inequalities in the distribution of the medical workforce remains a global challenge. Our results inform the discussion on the current strategy adopted in Brazil to increase access to primary healthcare in underserved areas.

  • health inequality
  • medical workforce
  • primary care
  • ambulatory admissions
  • cost–benefit analysis
  • more doctors programme
  • Brazil

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  • Handling editor Sanni Yaya

  • Twitter @CatherineStato1

  • Contributors EMM, TAHR, JRNV conceived the idea of the study. EMM and TAHR extracted the data. EMM did the analysis. EMM and TAHR drafted the manuscript. GV, CR, CS, JRNV revised the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data are publicly available.

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