Distribution
of vascular surgeons and angiologists and the Brazilian population:
an analysis with the members of the Brazilian Society of Angiology and
Vascular Surgery
(Portuguese
PDF version)
Jefferson
Kleber Forti,1 Maria Elizabeth Rennó de Castro Santos,2 João
Alfredo de Paula e Silva,3 Rodrigo Rodrigues Mariano,1 Renato
Gontijo,1 Raimundo Mairton Araújo Jr1
1.
Student of the specialization course in Angiology and Vascular Surgery,
Santa Casa de Belo Horizonte, MG, Brazil.
2. Preceptor, Angiology and Vascular Surgery Service, Santa
Casa de Belo Horizonte, MG, Brazil.
3.
Chief of the Angiology and Vascular Surgery Service, Santa Casa de
Belo Horizonte, MG, Brazil.
Correspondence:
Jefferson Kleber Forti
Rua Conselheiro Lafaiete, 2079/402 Bl. A, Sagrada Família
CEP 31035-560 - Belo Horizonte, MG, Brazil
E-mail: gallieus@hotmail.com
ABSTRACT
Objectives:
To correlate data about the real distribution of angiologists and
vascular surgeons in different Brazilian regions and the ideal proportion
of specialists per inhabitant.
Methods:
Data about the number and distribution of vascular surgeons and
angiologists was obtained from the list of members of the Brazilian
Society of Angiology and Vascular Surgery in 2004. The numbers concerning
the cities population was obtained from the National Census (2000)
carried out by the Brazilian Institute of Geography and Statistics.
The ideal specialist/inhabitants ratio was based on the World Health
Organization parameters, which are 17,000 inhabitants/specialist
for developing countries, and 35,000 inhabitants/specialist for
developing countries.
Results:
The South and Southeast Brazilian regions show a higher number of
specialists per inhabitant, the same fact was observed in the main
Brazilian cities and in locations nearby the major centers of education
in the area. In other Brazilian regions, there are fewer specialists
than the number considered appropriate.
Conclusion:
The competent entities should be concerned with providing a better
distribution of angiologists and vascular surgeons in the Brazilian
territory.
Key-words:
physician's distribution, medical specialties, demographic statistics.
J
Vasc Br 2004;3(4):350-6
The uneven
distribution of specialists in the Brazilian territory is of concern
to the entire society. Many alternatives were created in an attempt
to foster physicians to move to the cities other than capitals, such
as determining that students who graduated in public universities should
make their residency in pre-determined cities. However, this action
was not considered feasible by medical entities. The uneven distribution
of physicians and the discussion it raises end up generating high budgets
and worsening the public health crisis.
The main
reason for the unbalanced distribution is the lack of technical and
educational infrastructure in cities other than capitals, and this discourages
the settlement of new specialists in places distant from urban centers.
That is the reason why capital cities are overloaded, burdened with
elevated expenditures. On the other hand, investments are not made in
non-capital towns. In 1994, an agreement between the Fundação
Oswaldo Cruz and the Federal Council of Medicine carried
out a research intended to describe and get acquainted with the professional
status of the Brazilian physicians. The results of the survey were not
positive, revealing negative feelings and discontentment due to the
lack of professional perspectives.1 We are
aware that the Brazilian Department of Health (DH) has been searching
for solutions that would support the presence of specialists in non-capital
towns. In 2000, there was a movement to regulate the presence of foreign
physicians in Brazil so that they could work in those locations. However,
this has not showed to be the best alternative.2
There is
a total of 290,000 physicians working in Brazil today, their distribution,
however, does not follow the population distribution. Only 24% of the
population lives in capitals and 65.9% physicians work in these cities,
a ratio of 3.28 professionals per 1,000 inhabitant, in capitals, while
in non-capital towns this number falls to 0.53%.1
The ratio of angiologists and vascular surgeons per inhabitant in Brazil
is 1:81.561.
Usually,
98.3% physicians look for training and qualification in scientific societies,
which, on their turn, support the continued update of these professionals.2
After analyzing the report of the National Council of Medicine, Carvalho3
showed that some Brazilian regions have an important increase in the
number of physicians, which was proportional to the population increase.
The states with more universities have a higher concentration of professionals.3-5
According
to the World Health Organization (WHO) the demand for specialists is
determined by the needs of the population. Thus, there is not a formula
that determines a definite number of specialists for the population,
as this number may vary. The parameter set by the WHO was of one specialist
per 17,000 inhabitants,6-8 however, this number
is for developed countries. In developing countries, the relation of
one angiologist/vascular surgeon per 35,000 inhabitants is well accepted.
The purpose
of this paper is to provide information that may interest newly graduated
specialists, medical personnel and the government. We intend to contribute
to studies and incentives that would foster young specialists to work
in cities other than capitals, what would provide better quality in
healthcare assistance and generate positive consequences.
MATERIALS
AND METHODS
An appraisal
of all the members of the Brazilian Society of Angiology and Vascular
Surgery (SBACV) for the year 2004 was carried out. It provided, among
other information, the place where the professional works.4 Professionals
with specialization degree and the ones who do not have a specific degree
in vascular surgery, such as cardiovascular surgeons, general surgeons,
and dermatologists, who are not members of SBACV, were not included
in the study, although they currently comprise around 30% of the total
number of professionals who work in the area.1,7
The Brazilian
Institute of Statistics and Geography (IBGE) provided data concerning
the population of places where professionals of the SBACV work.7
The number
of physicians per inhabitant was given by the number of professionals
divided by the total population multiplied by 1,000. The result measures
the availability of specialists according to the geographic location.1
This factor is strongly dependent on the socioeconomic conditions of
the population and on the public healthcare policies.6
RESULTS
In 2004,
the distribution of angiologists and vascular surgeons was 57% in capitals
and 43% in non-capital towns (Figure 1). As for the gender variable,
most vascular surgeons are men (87%) against 13% women (see Figure 2).
 Figure
1 - Percentage of angiologists and vascular surgeons in capitals
and non-capital towns in Brazil in 2004.
Figure
2 - Percentage of gender in the angiology and vascular surgery specialty
in Brazil in 2004.
Concerning
the number of angiologists and vascular surgeons, the Southeast region
counts on 61% of specialists, a relation of 1:56,229 (Table 1). In the
South region, the proportion is 1:79,509 (Table 2), with 15% of specialists;
in the Center-west this relation is 1:74,372 (Table 3), with 7% of specialists;
in the Northeast region it is of 1:160,049 (Table 4), with 16% of specialists,
and in the North, the relation is 1:157,044, with 1% of specialists
(Table 4 and Figure 3).
Table
1 - Relation of angiologists and vascular surgeons (A/VS) distributed
among capitals and non-capital cities in the Southeast region in 2004
 |
| States
|
Population
(capitals) |
Population
(non-capital cities) |
Population
(total) |
Number
of A/VS in the capital |
Number
of A/VS in the capital |
Total
|
Total
of A/VS |
Relation
of A/VS: population (capital) |
Relation
de A/VS: population (non-capital cities) |
|
| Espírito
Santo |
302.633 |
3.052.391 |
3.352.024 |
39 |
30 |
69 |
|
1:7.760 |
1:111.734 |
| Minas
Gerais |
2.305.812
|
16.687.908 |
18.993.720 |
122
|
80 |
202 |
|
1:18.900
|
1:208.599 |
| Rio
de Janeiro |
5.974.081
|
8.413.144 |
14.387.225
|
206 |
238
|
444
|
|
1:29.000
|
1:35.349 |
| São
Paulo |
10.677.019 |
28.780.405
|
39.457.424 |
283
|
357 |
640 |
|
1:
37.728 |
1:80.617 |
| Total
|
19.259.545 |
56.933.848
|
76.190.393
|
650
|
705
|
1355
|
1:56.229
|
1:29.630
|
1:80.757 |
|
Table
2 - Relation of angiologists and vascular surgeons (A/VS) distributed
among capitals and non-capital towns in the South region in 2004.
|
| States
|
Population
(capitals) |
Population
(non-capital towns) |
Population
(total) |
Number
of A/VS in the capital |
Number
of A/VS in the capital |
Total
|
Total
of A/VS |
Relation
of A/VS: population (capital) |
Relation
de A/VS: population (non-capital towns) |
|
| Paraná
|
1.671.194
|
8.464.194
|
10.135.388
|
74
|
78
|
152
|
|
1:22.583 |
1:108.515 |
| Rio
Grande do Sul |
1.394.085 |
9.331.978 |
10.726.063
|
67
|
57
|
124
|
|
1:20.807
|
1:163.719 |
| Santa
Catarina |
369.102
|
5.405.076
|
5.774.178
|
11
|
48
|
59
|
|
1:33.555
|
1:112.606 |
| Total
|
3.434.381
|
23.201.248
|
26.635.629
|
152
|
183
|
335
|
1:79.509 |
1:22.595
|
1:126.783 |
|
Table
3 - Relation of angiologists and vascular surgeons (A/VS) distributed
among capitals and non-capital towns in the Center west region in 2004.
|
| States
|
Population
(capitals) |
Population
(non-capital towns) |
Population
(total) |
Number
of A/VS in the capital |
Number
of A/VS in the capital |
Total
|
Total
of A/VS |
Relation
of A/VS: population (capital) |
Relation
de A/VS: population (non-capital towns) |
|
| Distrito
Federal |
|
|
2.282.049
|
41 |
1 |
42
|
|
1:55.660
|
|
| Goiás
|
1.146.106
|
4.362.139
|
5.508.245
|
64
|
7
|
71
|
|
1:17.908
|
1:623.163 |
| Mato
Grosso |
508.156
|
2.240.989
|
2.749.145 |
8 |
3 |
11
|
|
1:63.519
|
1:746.996 |
| Mato
Grosso do Sul |
705.975
|
2.058.526
|
2.230.702
|
18 |
8 |
26 |
|
1:39.221 |
1:257.316 |
| Tocantins
|
172.176 |
1.090.468
|
1.262.644 |
4 |
4 |
8
|
|
1:43.044
|
1:272.617 |
| Total
|
2.532.413
|
9.752.122
|
14.032.785
|
135
|
23
|
158
|
1:74.372 |
1:18.759
|
1:424.005 |
|
Table
4 - Relation of angiologists and vascular surgeons (A/VS) distributed
among capitals and non-capital towns in the Northeast region in 2004.
|
| States
|
Population
(capitals) |
Population
(non-capital towns) |
Population
(total) |
Number
of A/VS in the capital |
Number
of A/VS in the capital |
Total
|
Total
of A/VS |
Relation
of A/VS: population (capital) |
Relation
de A/VS: population (non-capital towns) |
|
| Alagoas
|
849.734
|
2.131.176
|
2.980.910 |
26 |
2
|
28
|
|
1:32.682 |
1:1.065.588 |
| Bahia
|
2.556.429 |
11.305.645 |
13.862.074
|
75
|
14
|
89 |
|
1:34.086 |
1:807.546 |
| Ceará
|
2.256.233 |
5.720.330
|
7.976.563
|
31
|
1
|
32
|
|
1:72.782
|
1:5.720.330 |
| Maranhão
|
923.526
|
5.102.384
|
6.025.910 |
17 |
1
|
18
|
|
1:54.325 |
1:5.102.384 |
| Paraíba
|
628.838
|
2.935.106
|
3.563.944 |
16 |
6 |
22
|
|
1:39.302 |
1:489.184 |
| Pernambuco
|
1.461.320
|
6.862.591
|
8.323.911 |
81 |
11
|
92 |
|
1:18.040 |
1:84.723 |
| Piauí
|
751.464
|
2.225.795 |
2.977.259
|
10
|
0
|
10 |
|
1:75.146 |
1:2.225.795 |
| Rio
Grande do Norte |
744.794
|
2.217.313
|
2.962.107 |
21 |
0 |
21
|
|
1:35.466 |
1:2.217.313 |
| Sergipe
|
479.767
|
1.454.829
|
1.934.596 |
22
|
1
|
23
|
|
1:21.808
|
1.454.829 |
| Total
|
10.652.105 |
39.955.169
|
50.607.274 |
299 |
36 |
335
|
1:151.066
|
1:35.626
|
1:1.109.866 |
|
Figure
3 - Absolute number of angiologists and vascular surgeons distributed
among the Brazilian regions in 2004.
Vitória
is the capital with the highest concentration of specialists (1:7,760),
and Rio Branco has the least concentration (1:91,518) (Table 5). São
José do Rio Preto (SP) is the city with the highest relation specialist/population
(1:9,437).
Table
5 - Relation of angiologists and vascular surgeons (A/VS) distributed
among capitals and non-capital towns in the North region in 2004.
|
| States
|
Population
(capitals) |
Population
(non-capital towns) |
Population
(total) |
Number
of A/VS in the capital |
Number
of A/VS in the capital |
Total |
Total
of A/VS |
Relation
of A/VS: population (capital) |
Relation
de A/VS: population (non-capital towns) |
|
| Acre
|
274.555
|
346.079
|
620.634 |
3 |
0 |
3
|
|
1:91.518
|
1:346.079 |
| Amazonas
|
1.527.314
|
1.621.106
|
3.148.420
|
21 |
0
|
21
|
|
1:72.729 |
1:1.621.106 |
| Pará
|
1.342.202 |
5.507.979 |
6.850.181 |
22
|
2
|
24
|
|
1:61.009 |
1:2.753.989 |
| Total
|
3.144.071
|
7.475.164
|
10.619 |
46 |
2
|
48
|
1:221.234
|
1:68.349
|
1:3.737.582 |
|
Figures
4 and 5 show the distribution of angiologists and vascular surgeons
in capitals and in other towns. There is a large concentration of specialists
in the South and Southeast, as well as in capital cities.
Figure
4 - Geographic distribution of angiologists and vascular surgeons
in Brazilian capitals in 2004.
Figure
5 - Geographic distribution of angiologists and vascular surgeons
in non-capital towns in 2004.
DISCUSSION
It is possible
to determine, precisely, what would be the ideal proportion of specialists
per population by using the existing indexes. A detailed study on the
needs of each region and the demand of angiologists and vascular surgeons
would be important for the determination of a specific index. For classification
reasons, places with a relation higher than 1:70.000 were considered
to have a lack of specialists; between 1:35,000 and 1:69,999 were considered
balanced, with a trend to saturation, and with less than 1:34,999 were
considered critical.
The analysis
of geographical and temporal variations in the distribution of healthcare
providers together with the identification of unbalanced situations
encourages the elaboration of policies that support the migration of
new professionals to non-capital cities. We intend to contribute to
planning processes, management and evaluation of policies and actions
towards the formation of healthcare providers and their insertion in
the work market.3
The high
concentration of physicians in big centers indirectly contributes to
the bad conditions found away from capitals, with lack of budget and
poor investment. The lack of resources to settle new specialists in
cities other than capitals is another problem. The Brazilian Healthcare
Department (MS) and the Brazilian Society of Angiology and Vascular
Surgery (SBACV) could try to reach an agreement in order to find alternatives
for this problem.
The SBACV
should keep its members data always update. It is important also to
notice that the high concentration of specialists is near the big centers
and that the higher the number of workers, the less the gains are. Another
important fact is the estimate that 30% of specialists do not keep any
kind of link with the SBACV.1,5
In Brazil,
few studies established the ideal relation between the number of general
practitioners and/or specialists and the population needs, or even the
ideal relation between the number of physicians and inhabitants.1,5
As Brazil has a remarkable regional diversity, the WHO recommendation
of 1:1000 inhabitants cannot be generalized not even for specialties,
much less for Brazilian regions.5
It is fundamental
that the SBACV be aware of its associates situation, how they live,
what they do, which links they keep; members, on their turn should act
actively within the society, knowing the important role they have in
its development and strengthening.
CONCLUSION
This study
showed a high concentration of angiologists and vascular surgeons in
the Southeast region, especially in capitals and metropolitan areas.
In the south east and south regions there seems to have a considerable
distribution of this specialists in non-capital towns.
In the
North, North east, and Center-West regions, there is a high deficit
of angiologists and vascular surgeons, including places where there
are more complex and university hospitals.
There seems
to have a higher concentration of angiologists and vascular surgeons
in places where residency and specialization programs on this area are
offered.
It is then
clear that mechanisms that foster new specialists to leave jammed big
centers and find deficient places should be created. This change will
benefit not only patients, but healthcare providers as well, who would
have proper conditions to succeed.
Medical
societies have shown a great interest in promoting the migration of
their members to non-capital towns. SBACV seems to be concerned with
the issue, and this seems to be promising. It should continue to update
the list of members and, together with the HD, it should promote the
migration of specialists to non-capital towns by fostering the creation
of new study and training centers.
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1996.
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Machado MH. Perfil do Médico Brasileiro. Revista do SIMERS 2001;5:8-9.
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Carvalho RRP. Profissionais e curso médicos no Brasil. Brasília
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Sociedade Brasileira de Angiologia e Cirurgia Vascular. Relação
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Gorvarev A. WHO estimates of health personnel. World Health Organization;
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Instituto Brasileiro de Geografia e Estatística. Censo 2000.
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ML. O quadro atual do ensino de angiologia e da cirurgia vascular na
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