Enthusiastic applause from a handful of suited individuals led President Luiz Inácio Lula da Silva to the podium set up at the Planalto Palace. On that March 3, 2023, the Workers’ Party member announced the revival of a program that subjected thousands of Cuban healthcare professionals to slavery: the “Mais Médicos” program, launched ten years ago by former president Dilma Rousseff.
Excited by the reception from the audience, composed of ministers and ideologically aligned journalists, Lula defended the return of the program, which had been superseded by a more efficient project — the “Médicos pelo Brasil,” enacted in 2019 by the government of former president Jair Bolsonaro. “Our goal is not to know the nationality of the doctor, but the nationality of the patient, who is a Brazilian in need of healthcare,” said the Workers’ Party member.
Lula’s statement is an attempt to diminish the distrust of the population and specialized institutions towards the “Mais Médicos” program. But this discourse succumbs to the reality of the facts. From 2013 to 2018, for example, over 11,000 Cubans were in 3,000 Brazilian cities — occupying 60% of the total available positions. Brazilians with training abroad (5,000) and exchange participants (3,500) filled the remaining spots.
The “Mais Médicos” program benefited 63 million Brazilians across 4,000 municipalities. But no one benefited more than the Cuban political caste. According to the agreement brokered by the Pan American Health Organization (PAHO), the dictatorship established in Cuba had the right to pocket 70% of the doctors’ salaries, estimated at BRL 12,000. Another 25% went to those who actually worked, while 5% belonged to PAHO.
Sending doctors abroad was not only a way for the Cuban government to make money, but also a propaganda strategy. Havana intended to sell to the world the image of a medical powerhouse.
Extradited lab coats
As soon as Bolsonaro won the presidential elections in 2018, the Cuban dictatorship ordered its doctors to leave Brazil and return to their homeland. According to lawyer André de Santana Corrêa, representing the Cubans in the country, Havana’s decision goes against the Federal Constitution. “This measure violates four fundamental principles: acquired rights, human dignity, equality, and the social value of work,” he said.
Corrêa also argues that breaking the agreement is not justifiable because both governments called on the doctors to work in Brazil for six years – and they ended up being excluded at the end of the first three. “This brings us to the idea of modern slavery, as if Cuban doctors were commodities,” he emphasized. “They had the prospect of improving their living conditions. Unfortunately, that dream did not become a reality.”
Nearly 200 doctors went to court and asked for their contracts to be negotiated individually with the Brazilian government. In response, Havana began to move to find out who the citizens rebelling were. There was a special reason: Cuba would stop pocketing millions at the expense of others’ work.
A decision by the 9th Federal Court of the Federal District Judiciary Section ruled in favor of the Cuban doctors. According to the body, the issue is not about fulfilling a bilateral agreement, but about ensuring health professionals the possibility of exercising their freedom.
In the United States, the judiciary gave hope to professionals who felt deceived by the Cuban government and the organization that brokered the negotiation. In April 2022, the District of Columbia Court of Appeals granted four Cubans who worked in the Mais Médicos program the right to sue PAHO. In the complaint, the professionals claim to have performed work analogous to slavery between 2013 and 2018. A financial intermediary between Brasília and Havana, PAHO used its own US bank account to convert Brazilian reais into dollars and transfer a significant amount of money to the Cuban dictatorship, as reported by the Wall Street Journal.
It is in the wake of these problems that Lula’s team formulated Provisional Measure No. 1165/2023. The measure aims to reestablish Mais Médicos as the main program for directing professionals to the primary health care (PHC) network, which involves prevention, diagnosis, low-complexity treatments, rehabilitation, and palliative care. There are plans to hire 15,000 people in 2023, increasing the total number of participants to 28,000. In this scenario, the Médicos pelo Brasil program loses its prominence.
The program launched during the Bolsonaro administration received approval after extensive debate between the Ministry of Health, the National Congress, and specialized institutions representing 560,000 professionals licensed by the Regional Medical Councils (CRM). On the other hand, Lula’s Mais Médicos proposes unfavorable ideas for the medical profession, such as exclusive professional ties through scholarships and the hiring of professionals trained abroad – without the need for diploma revalidation.
“I participated in this debate in Parliament,” said federal deputy Marcel van Hattem (Novo-RS). “Although programs always have room for improvement, fortunately, Médicos pelo Brasil had the discussion with society that was lacking – intentionally, to a large extent – at the time of the launch of Mais Médicos by Dilma. Provisional Measure No. 1165/2023 had been signed on the same day that Cuban doctors were put on airplanes and sent as commodities to Brazil, without any discussion.”
Some differences between the programs stand out. In Médicos pelo Brasil, for example, it is possible to establish employment relationships with professionals after the scholarship period (two years). There is also the possibility of salary progression up to R$ 36,000 for doctors who work in regions of greater social vulnerability. In Mais Médicos, on the other hand, the remuneration model is exclusively through scholarships. Professionals receive about R$ 13,000, plus a bonus equivalent to R$ 2,500 per month, if they work for four years in vulnerable regions.
The distinctions do not stop there. Mais Médicos resumes the possibility of hiring professionals trained abroad — without a revalidated diploma — to fill possible care gaps. In Médicos pelo Brasil, professionals with training in other countries need to prove their competence through the National Exam for Revalidation of Medical Diplomas Issued by Foreign Higher Education Institutions (Revalida). In practice, the Lula government punishes vulnerable regions with unqualified doctors, further increasing the inequality between the care given to the neediest population and that granted to wealthier people.
Another difference: in Mais Médicos 2023, the selection of professionals follows subjective criteria. The calls for applications are made through public announcements – without structured selection processes. On the other hand, Médicos pelo Brasil establishes objective rules, and professionals must take an eliminatory exam.
Last but not least, Mais Médicos restricts the maximum period of service of professionals to eight years (a cycle of four years, extendable for the same period). In Médicos pelo Brasil, on the other hand, this time is indefinite for those who have the title of family and community medicine. The program resurrected by Lula does not provide for the fixation of doctors in communities – one of the most important issues in primary health care, according to experts consulted by Oeste.
“The PT isn’t the Workers’ Party?”
Now, Lula has a knot to untie: does the government intend to reinstate the program for importing foreign professionals through the PAHO? According to former Health Minister Marcelo Queiroga, the opposition should propose an amendment to MP 1165/2023 that would prevent the diversion of doctors’ resources to dictatorships.
“The money should stay with the professionals,” Queiroga emphasized. “I am against the current provisional measure. Isn’t the PT the Party of Workers? Why don’t they sign the doctors’ work contracts? Why do they want professionals to work clandestinely, without employment contracts?”
One of the active participants in the process of rebuilding MP 1165/2023 is Federal Deputy Adriana Ventura (Novo-SP), who presented an amendment prohibiting the transfer of resources to the Cuban dictatorship. “We cannot be complicit in the undue appropriation of payments,” said the deputy, arguing that the scholarships should be paid directly to the doctors, without diversion of resources to intermediaries or international organizations.
Hiran Gallo, President of the Federal Council of Medicine (CFM), also warns about the selection of professionals without a revalidated diploma. “This caution is based on statistical data,” he said. “Since its creation in 2011, Revalida has approved almost 12,000 doctors – of whom just over 7,000 are Brazilian (63%) trained abroad, and about 4,500 are foreigners (37%). The number of approved candidates represents 18% of the total of 62,000 candidates who registered for the exam.”
Although they are the majority among those approved, Gallo notes that Brazilian doctors trained abroad have a slightly worse performance than foreigners. The average for the former is 17.8%, with about 38,000 registered and just over 7,000 approved. Foreigners reach 18.85% approval, with 24,000 registered and nearly 4,500 approved.
“The explanation for this phenomenon lies in the low quality of medical schools, especially those on the borders of Brazil with Paraguay and Bolivia, which train most of the Brazilian students who take the Revalida,” noted the CFM president. “Despite the language barrier, students of other nationalities perform better than Brazilians. It is a worrying symptom.” For Gallo, admitting professionals with foreign diplomas without approval in Revalida – of any nationality – represents a risk situation for patients. “Especially for those who depend exclusively on the Unified Health System, that is, the most vulnerable part of the population,” he stressed.
CFM believes there is no need to sign agreements with foreign higher education institutions. With 389 courses currently, Brazil is the second country in the world in number of medical schools – behind only India, with 392.
According to Raphael Câmara, former national secretary of Primary Health Care at the Ministry of Health, Lula intends to implement Mais Médicos for financial reasons. “The amount used to hire professionals in Médicos pelo Brasil is twice that used in Mais Médicos,” he observed. “The salary is higher, and labor costs are high. The government prefers to hire more people, even if they are less qualified. The idea is to bet on volume and tell Brazilians that they are making more hires.”
In Médicos pelo Brasil, Câmara recalls that professionals had signed work contracts. “This link is similar to that established with Petrobras employees,” he explained. “Doctors cannot be fired without a concrete reason. To dismiss them, a complex administrative process is required. Those who work correctly remain in their positions. There is a career plan, which is absolutely essential.”
Patrícia Izetti, former coordinator of Chronic Diseases at the Ministry of Health, believes that the programs launched by Lula, Dilma, and Bolsonaro have different objectives. “Médicos pelo Brasil was built to be a state policy, not a government policy,” she argued. “The PT wants to end this project because it understands that it is a propaganda of the Bolsonaro government.”
In Waiting Mode
The opposition is still working to correct the mistakes of Mais Médicos, considered one of the main projects of the Lula-3 government. The return of this program, conceived by Dilma in 2013, symbolizes the resurrection of the worst political practices in Latin America – paternalism, violence, and oppression.
It is with this scenario in mind that lawmakers must act in the National Congress. When the discussion on Mais Médicos reaches the Chamber of Deputies and the Senate, representatives of the legislature will have to define which principles will guide the debate: respect for human rights, an essential value in liberal democracies, or veneration for dictatorships, a habitual behavior in underdeveloped countries.
Médicos pelo Brasil is an archetype of the best government policies because it has clear rules, finite resources, independent oversight, and defined objectives: to meet the needs of the poorest, who have no access to healthcare, and to reward competent professionals. Mais Médicos, on the other hand, is a perfect model of the inefficiency of state programs: obscure rules, endless resources, government-attached oversight, and indecipherable real objectives. Lula wants to take the country back to the ICU.