MARIO CESAR SCHEFFER
Projetos de Pesquisa
Unidades Organizacionais
Departamento de Medicina Preventiva, Faculdade de Medicina - Docente
LIM/39 - Laboratório de Processamento de Dados Biomédicos, Hospital das Clínicas, Faculdade de Medicina - Líder
LIM/39 - Laboratório de Processamento de Dados Biomédicos, Hospital das Clínicas, Faculdade de Medicina - Líder
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- 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(2020) RUSSO, Giuliano; CASSENOTE, Alex J. Flores; GUILLOUX, Aline G. Alves; SCHEFFER, Mario CesarBackground Primary health care (PHC) doctors' numbers are dwindling in high- as well as low-income countries, which is feared to hamper the achievement of Universal Health Coverage goals. As a large proportion of doctors are privately educated and private medical schools are becoming increasingly common in middle-income settings, there is a debate on whether private education represents a suitable mean to increase the supply of PHC physicians. We analyse the intentions to practice of medical residents in Brazil to understand whether these differ for public and private schools. Methods Drawing from the literature on the selection of medical specialties, we constructed a model for the determinants of medical students' intentions to practice in PHC, and used secondary data from a nationally representative sample of 4601 medical residents in Brazil to populate it. Multivariate analysis and multilevel cluster models were employed to explore the association between perspective physicians' choice of practice and types of schools attended, socio-economic characteristics, and their values and opinions on the profession. Results Only 3.7% of residents in our sample declared an intention to practice in PHC, with no significant association with the public or private nature of the medical schools attended. Instead, having attended a state secondary school (p = 0.028), having trained outside Brazil's wealthy South East (p < 0.001), not coming from an affluent family (p = 0.037), and not having a high valuation of career development opportunities (p < 0.001) were predictors of willingness to practice in PHC. A low consideration for quality of life, for opportunities for treating patients, and for the liberal aspects of the profession were also associated with future physicians' intentions to work in primary care (all p < 0.001). Conclusions In Brazil, training in public or private medical schools does not influence the intention to practice in PHC. But students from affluent backgrounds, with private secondary education, and graduating in the rich South East were found to be overrepresented in both types of training institutions, and this is what appears to negatively impact the selection of PHC careers. With a view to increasing the supply of PHC practitioners in middle-income countries, policies should focus on opening medical schools in rural areas and improving access for students from disadvantaged backgrounds.
- The differential impact of economic recessions on health systems in middle-income settings: a comparative case study of unequal states in Brazil(2020) ANDRIETTA, Lucas Salvador; LEVI, Maria Luiza; SCHEFFER, Mario C.; ALVES, Maria Teresa Seabra Soares de Britto e; OLIVEIRA, Bruno Luciano Carneiro Alves de; RUSSO, GiulianoIntroduction Although economic crises are common in low/middle-income countries (LMICs), the evidence of their impact on health systems is still scant. We conducted a comparative case study of Maranhao and Sao Paulo, two unevenly developed states in Brazil, to explore the health financing and system performance changes brought in by its 2014-2015 economic recession. Methods Drawing from economic and health system research literature, we designed a conceptual framework exploring the links between macroeconomic factors, labour markets, demand and supply of health services and system performance. We used data from the National Health Accounts and National Household Sample Survey to examine changes in Brazil's health spending over the 2010-2018 period. Data from the National Agency of Supplementary Health database and the public health budget information system were employed to compare and contrast health financing and system performance of Sao Paulo and Maranhao. Results Our analysis shows that Brazil's macroeconomic conditions deteriorated across the board after 2015-2016, with Sao Paulo's economy experiencing a wider setback than Maranhao's. We showed how public health expenditures flattened, while private health insurance expenditures increased due to the recession. Public financing patterns differed across the two states, as health funding in Maranhao continued to grow after the crisis years, as it was propped up by transfers to local governments. While public sector staff and beds per capita in Maranhao were not affected by the crisis, a decrease in public physicians was observed in Sao Paulo. Conclusion Our case study suggests that in a complex heterogeneous system, economic recessions reverberate unequally across its parts, as the effects are mediated by private spending, structure of the market and adjustments in public financing. Policies aimed at mitigating the effects of recessions in LMICs will need to take such differences into account.
- The Impact of the COVID-19 Pandemic on Physicians' Working Hours and Earnings in Sao Paulo and Maranhao States, Brazil(2022) OLIVEIRA, Bruno Luciano Carneiro Alves de; ANDRIETTA, Lucas Salvador; REIS, Regimarina Soares; CARVALHO, Ruth Helena de Souza Britto Ferreira de; ALVES, Maria Teresa Seabra Soares e; SCHEFFER, Mario Cesar; RUSSO, GiulianoEvidence exists on the health impacts of the current COVID-19 pandemic on health workers, but less is known about its impact on their work dynamics and livelihoods. This matters, as health workers-and physicians in particular-are a scarce and expensive resource in low- and middle-income countries (LMICs). Our cross-sectional survey set out to explore changes in working hours and earnings during the second year of the pandemic in a representative sample of 1183 physicians in Brazil's Sao Paulo (SP) and Maranhao (MA) states. Descriptive analysis and inferential statistics were employed to explore differences in working hours and earnings among public and private sector physicians across the two locations. The workloads and earnings of doctors working exclusively in the public sector increased the most in the second year of the epidemic, particularly in MA. Conversely, the largest proportion of private-only doctors in our sample saw a decrease in their working hours (48.4%, 95% CI 41.8-55.0), whereas the largest proportion of public-only doctors in MA saw an increase in their working hours (44.4%, 95% CI 38.0-50.8). Although earnings remained broadly stable in the public sector, a third of public sector-only physicians in MA saw an increase in their earnings (95% CI 24.4-36.2). More than half of private-only doctors across both states saw a decrease in their earnings (52.2%, 95% CI 45.6-58.8). The largest proportion of dual practitioners (the majority in Brazil and in our sample) maintained their pre-pandemic levels of income (38.8%, 95% CI 35.3-42.3). As public-sector doctors have been key in the fight against the pandemic, it is critical to invest in these cadres in order to develop epidemic preparedness in LMICs, and to find new ways to harness for-profit actors to deliver social benefits.
- What happened to health labour markets during COVID-19? Insights from the analysis of cross-sectional survey data on the perceptions of medical doctors in Brazil(2023) RUSSO, Giuliano; OLIVEIRA, Bruno Luciano Carneiro Alves Luciano de; CASSENOTE, Alex J. Flores; SCHEFFER, Mario C.ObjectivesTo examine physicians' perceptions of changing employment opportunities in Brazil, and gain an insight into labour markets in low/middle-income countries (LMICs) during the pandemic. Study designDescriptive and inferential analysis of a quantitative dataset from a representative cross-sectional survey of physicians of two Brazilian states. SettingsSao Paulo and Maranhao states in Brazil. ParticipantsRepresentative sample of 1183 physicians. Outcome measuresWe estimated prevalence and 95% CIs for physicians' perceptions of changes in demand and supply of doctors, as well as changes in prices of medical services for facilities of practice in the two states, stratified by public, private and dual-practice physicians. ResultsMost doctors reported increased job opportunities in the public sector (54.9%, 95% CI 52.0% to 57.7%), particularly in Maranhao state (65.0%, 95% CI 60.9% to 68.9%). For the private sector, increased opportunities were reported only in large private hospitals (46.7%, 95% CI 43.9% to 49.6%) but not in smaller clinics. We recorded perceptions of slight increases in availability of doctors in Maranhao, particularly in the public sector (51.4%, 95% CI 43.2% to 59.5%). Younger doctors recounted increased vacancies in the public sector (64%, 95% CI 58.1% to 68.1%), older doctors only in walk-in clinics in Maranhao (47.5%, 95% CI 39.9% to 55.1%). Those working directly with patients with COVID-19 saw opportunities in public hospitals (65%, 95% CI 62.3% to 68.4%) and in large private ones (55%, 95% CI 51.8% to 59.1%). ConclusionsOur findings hint that health labour markets in LMICs may not necessarily shrink during epidemics, and that impacts will depend on the balance of public and private services in national health systems.
- The multiple uses of telemedicine during the pandemic: the evidence from a cross-sectional survey of medical doctors in Brazil(2022) SCHEFFER, Mario; CASSENOTE, Alex; ALVES, Maria Teresa Seabra Soares de Britto E; RUSSO, GiulianoBackground The use of telemedicine, or the provision of healthcare and communication services through distance-based technologies, has increased substantially since the 2019 novel coronavirus (COVID-19) pandemic. However, it is still unclear what are the innovative features of the widespread use of such modality, its forms of employment and the context in which it is used across pluralist health systems, particularly in low- and middle-income settings. We have sought to provide empirical evidence on the above issues by analysing the responses of medical doctors in a representative cross-sectional survey in two states in Brazil: Sao Paulo and Maranhao. Methods We analysed the responses of 1,183 physicians to a survey on the impact of COVID-19 on their livelihood and working practice. Two independent samples per state were calculated based on a total of 152,511 active medical registries in Sao Paulo and Maranhao. Proportional stratified sampling was performed and the distributions for gender, age, state and location of address (capital or countryside) were preserved. The survey contained questions on the frequency of physicians' employment of telemedicine services; the specific activities where these were employed, and; the forms in which the pandemic had influenced the adoption or consolidation of this technology. We performed descriptive and univariate analysis based on the chi-square test or Fisher's exact test for the qualitative data, and the Mann-Whitney test in the quantitative cases. Data were shown as absolute frequency and proportion with a 95% confidence interval. Results In our sample of physicians, telemedicine was employed as a form of clinical collaboration by most doctors (76.0%, 95 CI 73.6-78.5), but only less than a third of them (30.6%, 95 CI 28.0-33.3) used it as a modality to provide healthcare services. During the pandemic, telemedicine was used predominantly in COVID-19-related areas, particularly for hospital-based in-patient services, and in private clinics and ambulatory settings. Male, younger doctors used it the most. Doctors in Sao Paulo employed telemedicine more frequently than in Maranhao (p < 0.001), in urban settings more than in rural areas (p < 0.001). Approximately three-quarters of doctors in large hospitals reported using telemedicine services (78.3%, 95 CI 75.9-80.6), followed by doctors working for smaller private clinics (66.4%, 95 CI 63.7-69.1), and by a smaller proportion of primary care doctors (58.4%, 95 CI 55.6-61.2). Conclusions Our study suggests that telemedicine may have helped ensure and expand the range of communication and healthcare services in low- and middle-income settings during the COVID-19 pandemic. However, the modality appears to lend itself to be disproportionally used by doctors working in specific, priviledged sections of pluralistic health systems, and presumably by patients seeking care there. Regulation and incentives will be required to support the use of the technology across health systems in low- and middle-income countries in order to increase access to services for less disadvantaged populations.
- Effects of individual and organizational factors on job tenure of primary care physicians: A multilevel analysis from Brazil(2023) DIAS, Ivan Wilson Hossni; MATIJASEVICH, Alicia; RUSSO, Giuliano; SCHEFFER, Mario Cesar; LOERBROKS, AdrianBackgroundThe short tenure of primary care physicians undermines the continuity of care, compromising health outcomes in low-, middle and in high-income countries. The purpose of this study was to investigate the contextual and individual factors associated with the tenure of physician in Primary Health Care (PHC) services. We consider individual-level sociodemographic variables such as education and work-related variables, as well as the characteristics of employers and services. MethodsThis study is a retrospective cohort study of 2,335 physicians in 284 Primary Health Care Units across the Sao Paulo, Brazil, public health care system from 2016 to 2020. A multivariate hierarchical model was selected, and an adjusted Cox regression with multilevel analysis was employed. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was used to report the findings from the study. ResultsThe average physician tenure was 14.54 +/- 12.89 months, and the median was 10.94 months. Differences between Primary Health Care Units accounted for 10.83% of the variance observed in the outcome, while the employing organizations were responsible for only 2.30%. The physician characteristics associated with higher tenure in PHC were age at hire, i.e., being between 30 and 60 years old, [HR: 0.84, 95% CI: (0.75-0.95)] and professional experience over five years [HR: 0.76, 95% CI: (0.59-0.96)]. Specialties not related to PHC practices were associated with a short tenure [HR: 1.25, 95% CI: (1.02-1.54)]. ConclusionDifferences between Primary Health Care Units and in the individual characteristics, such as specializations and experience, are related to the low tenure of professionals, but such characteristics can be changed through investments in PHC infrastructure and changes in work conditions, policies, training, and human resource policies. Finding a remedy for the short tenure of physicians is essential for guaranteeing a robust PHC system that can contribute to universal, resilient, and proactive health care.
- Revolving doors and conflicts of interest in health regulatory agencies in Brazil(2020) SCHEFFER, Mario C.; PASTOR-VALERO, Maria; RUSSO, Giuliano; HERNANDEZ-AGUADO, Ildefonso
- Physician's sociodemographic profile and distribution across public and private health care: an insight into physicians' dual practice in Brazil(2018) MIOTTO, Bruno Alonso; GUILLOUX, Aline Gil Alves; CASSENOTE, Alex Jones Flores; MAINARDI, Giulia Marcelino; RUSSO, Giuliano; SCHEFFER, Mario CesarBackground: The intertwined relation between public and private care in Brazil is reshaping the medical profession, possibly affecting the distribution and profile of the country's medical workforce. Physicians' simultaneous engagement in public and private services is a common and unregulated practice in Brazil, but the influence played by contextual factors and personal characteristics over dual practice engagement are still poorly understood. This study aimed at exploring the sociodemographic profile of Brazilian physicians to shed light on the links between their personal characteristics and their distribution across public and private services. Methods: A nation-wide cross-sectional study using primary data was conducted in 2014. A representative sample size of 2400 physicians was calculated based on the National Council of Medicine database registries; telephone interviews were conducted to explore physicians' sociodemographic characteristics and their engagement with public and private services. Results: From the 2400 physicians included, 51.45% were currently working in both the public and private services, while 26.95% and 21.58% were working exclusively in the private and public sectors, respectively. Public sector physicians were found to be younger (PR 0.84 [0.68-0.89]; PR 0.47 [0.38-0.56]), less experienced (PR 0.78 [0.73-0.94]; PR 0.44 [0.36-0.53]) and predominantly female (PR 0.79 [0.71-0.88]; PR 0.68 [0.6-0.78]) when compared to dual and private practitioners; their income was substantially lower than those working exclusively for the private (PR 0.58 [0.48-0.69]) and mixed sectors (PR 0.31 [0.25-0.37]). Conversely, physicians from the private sector were found to be typically senior (PR 1.96 [1.58-2.43]), specialized (PR 1.29 [1.17-1.42]) and male (PR 1.35 [1.21-1.51]), often working less than 20 h per week (PR 2.04 [1.4-2.96]). Dual practitioners were mostly middle-aged (PR 1.3 [1.16-1.45]), male specialists with 10 to 30 years of medical practice (PR 1.23 [1.11-1.37]). Conclusion: The study shows that more than half of Brazilian physicians currently engage with dual practice, while only one fifth dedicate exclusively to public services, highlighting also substantial differences in sociodemographic and work-related characteristics between public, private and dual-practitioners. These results are consistent with the international literature suggesting that physicians' sociodemographic characteristics can help predict dual practice forms and prevalence in a country.
- How the 'plates' of a health system can shift, change and adjust during economic recessions: A qualitative interview study of public and private health providers in Brazil's Sao Paulo and Maranhao states(2020) RUSSO, Giuliano; LEVI, Maria Luiza; ALVES, Maria Teresa Seabra Soares de Britto e; OLIVEIRA, Bruno Luciano Carneiro Alves de; CARVALHO, Ruth Helena de Souza Britto Ferreira de; ANDRIETTA, Lucas Salvador; FILIPPON, Jonathan Goncalves; SCHEFFER, Mario Cesar; GARCIA, JonathanBackground Economic recessions carry an impact on population health and access to care; less is known on how health systems adapt to the conditions brought by a downturn. This particularly matters now that the COVID-19 epidemic is putting health systems under stress. Brazil is one of the world's most affected countries, and its health system was already experiencing the aftermath of the 2015 recession. Methods Between 2018 and 2019 we conducted 46 semi-structured interviews with health practitioners, managers and policy-makers to explore the impact of the 2015 recession on public and private providers in prosperous (Sao Paulo) and impoverished (Maranhao) states in Brazil. Thematic analysis was employed to identify drivers and consequences of system adaptation and coping strategies. Nvivo software was used to aid data collection and analysis. We followed the Standards for Reporting Qualitative Research to provide an account of the findings. Results We found the concept of 'health sector crisis' to be politically charged among healthcare providers in Sao Paulo and Maranhao. Contrary to expectations, the public sector was reported to have found ways to compensate for diminishing federal funding, having outsourced services and adopted flexible-if insecure-working arrangements. Following a drop in employment and health plans, private health insurance companies have streamlined their offer, at times at the expenses of coverage. Low-cost walk-in clinics were hit hard by the recession, but were also credited for having moved to cater for higher-income customers in Maranhao. Conclusions The 'plates' of a health system may shift and adjust in unexpected ways in response to recessions, and some of these changes might outlast the crisis. As low-income countries enter post-COVID economic recessions, it will be important to monitor the adjustments taking place in health systems, to ensure that past gains in access to care and job security are not eroded.