Brazil: Back to the Guilds?

There is a proposal in the National Congress to amend the law regulating medical schools by adding an additional requirement to the overall curriculum. According to the proposal, students who finish medical school would still have to pass a proficiency exam in order to start practicing medicine. The additional exam would be proctored by the Federal Council of Medicine (CFM). The proposal, however, is bad for both the country and its public health.

The results of an exam proctored in 2007 by the Sao Paulo Regional Council of Medicine (CREMESP) for students who just finished Medical school were very poor. Indeed, out of a total of 833 medical students only 367 scored above 60% in the first phase, and only 265 were indeed approved. A similar exam (ENADE) was offered by the Education Minister (MEC) in 2004: the students who had just finished their Medical school undergraduate degree reported a national average of 49.5 out of 100, a poor outcome. These results corroborate the idea that a great majority of newly incoming medical doctors are not well trained. This in turn, would justify an additional control by the CFM and higher standards imposed by the MEC.

The broader picture, however, is that Brazil is a poor and unequal country with a low quality public health system that is used by the majority of the population. Similarly, the educational performance scores in Brazil as suggested by the average scores reported by the ENADE for all undergraduate degrees are even worse, Medicine is among the most prestigious degrees, with 298,000 candidates in 2005 but with only 14,000 slots in the Medical schools. In that same year, out of 4.5 million students pursuing a college degree, only 69,000 were enrolled in medical school. In order for the students to be in good standards in the medical program they need above the average grades. The six-year degree program requires a great amount of investment by the student and by the school (or university). Although the tests cannot be directly compared, the national average in Medicine at the ENADE in 2004 is greater than the ones from other undergraduate degrees.

The initial salary of a medical doctor (MD) is basically due to the limited supply of professionals and the great amount of investment allocated during their college years. Indeed, the average salary by a recently graduated doctor is the highest among all the undergraduate fields; (it is 22% greater than civil engineers and 67% higher than business administrators). According to the CREMESP, Sao Paulo has an excessive number of doctors. However, the following chart displays the number of MDs by 1000 habitants versus the per capita income of a range of countries as well as the trend line (positive and significant) between the two variables. In both years – 2000 and 2005 – Brazil is below the world trend and is close to India, China, Chile and Turkey. In contrast, European countries display greater MD density. More precisely, Sao Paulo had 2.23 MD for each 1,000 people in 2005 versus 0.56 in the northern state of Maranhao. Given that the per capita income of Sao Paulo is 30% greater than the national average, Sao Paulo would still be below the trend line . In other words, evidence shows that the number of MDs in Brazil is far from excessive, especially in the most impoverished regions. Besides, on average, Medical schoool students are better equipped than those from other professions and usually are well placed in the job market.

Wouldn’t it be better to improve the MD’s minimum quality standards? Yes, for sure. With time, the labor market pressures, the greater transparency provided by the ENADE and the role of MEC tend to contribute to improvements in the Medical school courses. In the short run, the average quality can be improved by a decrease in the supply through a more rigorous national proficiency exam, similarly to the proposal. However, what is the cost of such alternative? Is it feasible to have high quality standards in the next years, similar to the more developed countries and still have enough doctors to meet the needs of the Brazilian population? If this is not possible, what is the best option: 1) a greater number of MDs, with an average lower than excellence standards ?; or 2) a medical elite that would clinic for the 20% share of the richest Brazilians?

Nevertheless, even if we accept the idea of an additional proficiency exam, it is key that the criteria should be defined by the whole society and not by the medical professional alone. One alternative is to make the ENADE mandatory test to all medical schools instead of keeping the current sampling process. The grade obtained by the students would be included in their diplomas and or would be compulsorily released at the request of a patient or the employer. On the other hand, if we grant the CFM power to control the access to the medical profession we would be going back in time prior to the industrial revolution, where artisan associations were in charge of regulating their professional activities. Still, the conflict of interest is clear, despite all the potential good intentions. This is so because the incumbent’s conditions of employment and income are inversely related to the number of new entrants (the newly graduated MDs), creating an incentive to limit the supply below the socially optimal.

Despite the relevant appeal that such proposal may entail, it is best to leave aside this idea. In exchange we would grant the MEC the task of regulating the educational system and allow the market the task of selecting the doctors according to their competency and capability.

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Originally published by Valor Economico and translated to English by RGE monitor.