Brazil’s “More Doctors” Program: Trading Rights for Social Justice

Ms. Rousseff’s administration has been complicit with Cuba’s exploitation of their doctors working in Brazil, affronting constitutional principles, international law, and national sovereignty

Brazil has long struggled to provide medical care to small towns and rural communities.  Few doctors have applied to vacant positions in these places due to the lack of career prospects and of basic infrastructure.  Under the free Unified Health System, the only healthcare option for three quarters of Brazilians, getting simple diagnostic exams or an appointment may take months, even years.  Smaller towns often lack equipment and medicaments.  Faced with such constraints, many doctors remain in bigger cities, where more than half work simultaneously for the public and private health care systems.  Consequently, patients from remote localities must travel long distances for treatment.

To bring doctors into those critical areas, President Dilma Rousseff in July 2013 launched the Programa Mais Médicos (PMM, “More Doctors Program”), an enterprise that has achieved major progress toward universalizing primary health care for previously unassisted populations.  However, the program has a problematic component, often played down by government-friendly media: a shady deal with Cuba, which promotes the exploitation of Cuban doctors in the business of bringing about social justice.  The Castro regime capitalizes on their overseas doctors, retaining most of their pay, with the complicity of the Brazilian government.

The Program and Its Achievements

The PMM has three main axes: an emergency provision of primary assistance for neglected areas, changes in the medical training system, and investments in infrastructure.  The recruitment policy prioritizes Brazilian or foreign doctors registered in Brazil and, second, Brazilians trained abroad, who are required to pass an exam to validate their license.  Yet if the number of candidates does not meet the demands, the third call is to foreign doctors trained abroad, who are exempt from the validation exam.  They can only work within the scope of the PMM – primary health care – in places where they were assigned, for a three-year period, extendable once. In this way, they are hired individually by the Brazilian government as temporary exchange health workers ­– except for the Cubans, as discussed below.

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According to the PMM webpage, 18,240 doctors have signed up, attending to 63 million people in 4,058 municipalities.  Whether or not official claims are accurate, the program has clearly benefited millions of Brazilians, including remote rural and indigenous communities.  A study showed that 85% of users said the PMM had improved medical care, while 93% of its doctors were satisfied.  Moreover, the program has reduced hospitalizations and increased medical appointments.  Finally, the doctor/patient ratio has improved to 2.11 per thousand, twice as much as recommended by the World Health Organization (WHO).  However, distribution remains a problem: 55% of doctors are concentrated in capital cities, where only a quarter of Brazilians actually live.

The Controversial Brazil-Pan American Health Organization Agreement

Despite its undeniable achievements, the PMM has a highly questionable aspect.  According to the Pan American Health Organization (PAHO) by mid-2015 over 11,400 of the recruited doctors were Cubans, with 1,500 other foreign doctors and 5,300 Brazilians.  Although Brazil pays a monthly R$ 10,500 (about US$ 4,400 at the program’s launch, currently US$ 2,650) to each doctor, the Cubans are working under different terms, receiving only a fraction of that amount.

They come to Brazil through an agreement between both countries, intermediated by the PAHO. Brazil pays out the same amount for each participant, but as the Health Minister admitted, Cuban doctors only receive US$ 1,245.  The rest is transferred to the PAHO, which then passes the resources along to Havana.  Therefore, it is a de facto Brazil-Cuba deal under the guise of the PAHO.  Cuban exchange doctors today are getting about a third of what their colleagues receive, while the Castro regime pockets the bulk of their earnings.  By July 2015, Havana had received an estimated R$ 2.7 billion in transfers from Brazil.

Cuban authorities do not provide any information on the amounts paid or retained, and since the terms of the agreement remain confidential, much of what is known about it came from revelations by Cuban doctors who abandoned the program, leaked recordings and documents, as well as investigations by the Brazilian Federal Audit Court (TCU).  An English-language report of the Spanish Audit Court, which examined financial statements of the PAHO, noted that although some lawsuits against the PMM had been closed, new ones are still “pending decisions from […] Brazilian Courts.”  It also pointed out that knowledge of “the total amount of resources actually used in the project implementation” was limited.

With a saturated supply of physicians, 6.7 per thousand people, Cuba has long sent them overseas to raise revenue.  According to their state-run newspaper, in 2014 the Castro regime expected to collect US$ 8.2 billion out of health professionals working abroad.  Furthermore, what Cuban doctors receive for their work overseas is often many times what they earn at home.  Overall, it is not surprising that about 25,000 Cuban doctors work abroad, especially in Latin America and Africa.  However, neither Brazil’s need for their work nor their choice to sign up for the PMM are good excuses to sweep their oppression under the rug.

Revealing Leaks

In March 2015, a leaked recording of a meeting between Maria Alice Barbosa Fortunato, the PAHO coordinator heading the PMM, and six advisors of Ms. Rousseff’s administration, during the program’s drafting stage, shed some light on the shady pact with Cuba.  It showed the Brazilian government’s attempt to mask the fact that the Brazil-PAHO agreement would serve as a front for a deal with Havana.  In the meeting, Ms. Fortunato comments:

“If we put [the words] ‘Cuban government’ [in the agreement term], if our document is public, anyone [who reads it] will understand that we are dribbling the bilateral agreement thing, and this can blow [the deal] apart.”

She then proposes opening up the PMM to other countries in the region:

“We can put in this term ‘Mercosur’ and ‘Unasur’, which will cost about R$ 2 million, to take the focus out of Cuba only, and include countries from Mercosur and Unasur.  R$ 2 million compared to R$ 1.6 billion [for Cuba], do you think this will be a problem in the Judiciary?”

She later elaborates on how to mask the inclusion of watchdogs of the Cuban regime, which come to Brazil to prevent defections by the doctors:

“I’ll put, for instance, if it is 9,000 doctors and 50 advisors, I’ll put ‘9,050 exchange doctors’ in my term, because in the [official] program [they] don’t enter, and that’s what I want to defend.”

The participants then deliberate on the percentages of the transfers the Castro regime should keep or pay to the Cuban physicians.  An advisor mentions that Marco Aurélio Garcia, a foreign policy advisor to Ms. Rousseff, had proposed the following arrangement:

“60 to the government, 40 to the doctor. Marco Aurélio put this in the meeting, just spreading the news.”

Ms. Fortunato disagrees:

“The [labor] relation is with their government, it is up for them to decide.  We are not going to interfere on how much the Cuban doctor will receive.”

The participants also discuss the clandestine status of the agreement.  An advisor comments that the Foreign Affairs Ministry (MRE) was not involved in the negotiations:

“I would send [the agreement term to the MRE] in the last place.  Things there are leaking more than WikiLeaks.  I would send an e-email. […]  We are talking things with Cuba without having any high-level decision made.”

Brazilian authorities have repeatedly said the agreement is only with the PAHO, claiming that Brazil is not accountable for what Cuba does to their doctors.  They argue that the Cuban doctors in the PMM are temporary scholarship holders, and as such, their labor relations are exclusively with Havana.  The PAHO, in turn, also denied any illegality in their role.

Jeopardized Rights and Harassment

Although brushed off by officials, criticism to this deal has solid legal and ethical fundaments.  Cuban doctors are clearly in disadvantage compared to their Brazilian and other foreign cohorts.  This is happening in spite of articles V and VII of the Constitution, which establish equal rights for all “residing in the country” and generally the principle of ‘equal pay for equal work’.  Furthermore, international law is adamant on the rights of migrant health workers.  The WHO Global Code of Practice on the International Recruitment of Health Personnel states, for instance, that:

International recruitment of health personnel should be conducted in accordance with the principles of transparency [and] fairness […] (article 3.5)

Migrant health personnel should be hired, promoted and remunerated […] on the basis of equality of treatment with the domestically trained health workforce.  (article 4.4)

[T]he Code applies equally to those recruited to work on a temporary or permanent basis.  (article 4.7)

In violation of these norms and principles, Brazil has been complicit with the oppression of the Castro regime.  Various Cuban defectors declared that they did not know about the relative gap in their pay.  Moreover, to prevent defections, they cannot bring their families, except for short visits.  Some who did suffered threats of being sacked from the PMM or losing their diploma.  In 2015, a Cuban Minister personally came to Brazil to demand the return of families overstaying in the country.

Some defectors have spoken out against these abuses.  Ramona Rodríguez, the first Cuban doctor to abandon the program, said that she learned about the gap in pay when talking to her cohorts.  She also claimed she had been deceived about the possibility of bringing her family along.  Another doctor, Dianelys San Roman Parrado, escaped to Miami with her husband and child.  Her family had come to Brazil to visit her, and was receiving pressure “from the Cuban government” to return.   Doctors also fear reprisals to their families in Cuba. For instance, Raul Vargas said:

“In Cuba, I think we doctors are a merchandise.  They train you to be a doctor, to later raise revenue, to raise money”. […]  “My daughter is finishing [high school] now, to enter university.  Universities there are all public.  There are no private universities, and a retaliation that [she] may suffer is that they don’t let her enter university.”

Closing Thoughts

The PMM has helped to universalize medical care in Brazil, improving the lives of millions among the poorest in the country.  Even Cuban doctors and their families have benefited from it, at least as long as they play by the rules of the Castro regime.  That might explain why, in spite of the unfair treatment they get, the number of defections among Cuban doctors is inferior to that of other nationalities, only 47 by mid-2015.  Nevertheless, the agreement governing the labor relations of Cuban physicians is clearly problematic not only in legal but also in ethical terms.  The Castro regime’s exploitation of their doctors within Brazilian borders, with the complicity of Ms. Rousseff’s administration, affronts their constitutional rights, international law, and Brazilian sovereignty.

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