Dissertation summary
The availability of trained health workforce is regarded as one of the key components of access to healthcare services. Greater availability of health personnel is associated with higher utilization of services, improvements in the quality of care and better health outcomes. Yet, the geographic imbalances in the distribution of health workforce remains a longstanding concern in many countries across all income levels.
Similar to many developing countries, Brazil faces considerable challenges in access to healthcare service. In 1994, the Family Health Strategy (FHS) was launched with the aim of improving access to health. Today, the FHS has become the main platform that guarantees universal access to healthcare services for all Brazilians, reaching more than 122 million people. Since its launch, the FHS was scaled-up rapidly across Brazil; though this expansion has been uneven with stark differences across states and municipalities. The geographic imbalances in the distribution of physicians has been argued as one of the most difficult challenges hindering the expansion of FHS.
Against this backdrop, the Brazilian Ministry of Health (MOH) introduced a supply-side intervention called the More Doctors Program (MDP) in 2013. The MDP was a complex intervention that entailed channeling financial resources to increase medical training in Brazilian universities, introducing salary incentives to recruit and retain Brazilian physicians to serve in underserved areas, and recruiting a cadre of foreign physicians to serve in communities, where previous attempts at attracting Brazilian physicians had proven insufficient.
In my dissertation, I examine the impact of the More Doctors Program on Brazil's health system performance using quasi-experimental and spatial methods.
Paper I. Did Brazil’s More Doctors Program (MDP) reduce gaps in access to primary care services?
This paper studies the More Doctors Program in Brazil on access to health services. We measure access through two outcomes: (i) physician density and (ii) the proportion of population covered by the FHS. Our analytical strategy exploits the geographic variation in the uptake of the program as a quasi-experiment using data from publicly available sources for the years 2009-2017. We integrate coarsened exact matching and difference-in-difference methodologies. We investigate heterogenous treatment effects by stratifying our results by geographic regions, municipality size, location type and level of socioeconomic development.
Paper II. The impact of Brazil’s More Doctor Program on the utilization of primary care services
This paper examines the impact of Brazil’s the More Doctors Program on the utilization primary care services that are typically provided by family health teams. More specifically, we evaluate whether the program led to increased utilization of cervical and breast cancer screening. Similar to the earlier paper, we examine heterogenous treatment effects.
Paper III. Assessing the determinants of More Doctor Program prioritization criteria between 2013-2017
In the existing literature, there is no agreement on how to define underserved communities in resource constrained settings. In Brazil, the federal government used a set of explicitly defined criteria to determine eligibility to receive physicians through the program. Between 2013-2017, the eligibility criteria were revised several times to ensure better targeting of underserved communities. Using municipality-aggregated data from publicly available sources, we study the program eligibility criteria by mapping its evolution over time using geospatial methods and examine the level of adherence to the eligibility criteria. We investigate the subnational-level determinants of eligibility using a multi-level regression design using a panel dataset.