Abstract
BackgroundPrimary 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.MethodsDrawing 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.ResultsOnly 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).ConclusionsIn 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.
Highlights
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
Our hypothesis was that proxy variables for gender [30], family background [31], and socially sensitive views on the profession [32, 33] were going to show a positive association with the intention to practice in primary care settings
As the students’ response rate differed across strata in our sample, we investigated cluster effects in the outcome variable, and a high variability was detected between clusters, which was visible in the difference of frequencies for variables in the weighted and unweighted sample (Table 2)
Summary
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. Shortages of primary care physicians are increasingly reported throughout the world, as fewer medical students select PHC and family medicine specialties in rich [2,3,4] as well as poorer countries [5]. As primary care specialties typically fetch comparatively lower salaries than hospital ones [6], and rank consistently low for professional prestige in the medical community [7], scholars and policy-makers worry that filling general practice positions in public healthcare systems will become increasingly difficult, for lowincome and rural areas [8]. Labour market forces and prospective revenues have been identified as major influencing factors in the selection of specialties, with the expected Rate of Return to Education for specific medical professions being a key, and still largely unexplored, determinant of students’ decisions [12]
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