Where's the doctor? Targeting, adoption, and decentralized governance of the Mais Médicos (More Doctors) program and health policy in Brazil

ABSTRACT

Championed by its supporters as a program for the underprivileged and criticized by its opponents as an electoral program, the Mais Médicos program aimed to provide primary care doctors to lacking regions of Brazil and is a major social policy of the Dilma Roussef (PT) presidency. This thesis assesses how political factors influenced the distribution of resources of this program in two manners (1) it examines the distribution of doctors among all Brazilian municipalities and (2) evaluates where these doctors were allocated at a micro-level in the cities of Fortaleza, led by the center-left Roberto Claudio (PSB) administration, and Salvador, led by the right-wing ACM Neto (DEM) administration. There are several findings in this analysis. Employing matching methods, I find that mayors of the PT (d = .36 SD) and a high representation in city councils of the PT (d = .14 SD) led to a higher number of program doctors. Other left parties not including the PT did not lead to a significant increase in program doctors, regardless of nationality, compared to non-left parties. Panel regression analysis indicates that program resources correlated with municipalities of greater "need", as determined by poverty levels and territorially protected populations, and there is no evidence that the national government distributed doctors to benefit their electoral chances in the 2014 Presidential elections. The evidence of association between program resources and greater subnational electoral competition, as measured by the margin of victory in the 2012 municipal elections, is weak - the magnitude of this relationship is very low and only significant at the 10% level for municipalities with 25,000 inhabitants or more. There is the strong negative correlation between ESF Coverage Rates and private insurance rates, respectively, and program doctor rates. This suggests that mayors in areas with a higher percentage of their population with private insurance avoided program resources and areas with low ESF Coverage rates received doctors. In the comparative analysis of Fortaleza and Salvador, I find that both cities aimed to distribute doctors to health centers in poor neighborhoods, although Fortaleza was more successful in doing so due to the legacy of the Family Health Strategy being stronger there than in Salvador. This legacy is largely attributable to the past presence of the PT in Fortaleza, which expanded the Family Health Strategy program.(AU)