How the Brazilian government bypassed Congress to bring in Cuban doctors

Marcelo Soares . Nov 21, 2018

Cuban doctor with Brazilian patient

Last week, the Cuban government announced it was pulling out of the More Doctors Program, which sends healthcare professionals to remote areas around Brazil. The move came after statements made by President-elect Jair Bolsonaro, who wanted to impose conditions on Cuba in order to keep the program going. At the time, we argued that Brazil seriously needs these doctors. Today, however, we will focus on the problems with the More Doctors Program, beginning with how Brazil and Cuba negotiated to bypass Congress.

Telegrams from the Brazilian embassy in Cuba allow us to reconstruct the negotiations between the two countries in order to create the More Doctors Program. Classified as confidential and kept secret for five years, these cables belie part of the official story told to Brazilians.

The documents show, for example, that the program was offered by Cuba and was already negotiated a year before then-President Dilma Rousseff presented it, in response to the June 2013 protests. The negotiations were kept secret to avoid negative reactions from the medical community. At these meetings, Havana made the demands which have now been criticized by President-elect Jair Bolsonaro, and whose threats of cancellation spurred Cuba to unilaterally pull the plug.

<h2>No formal attachment to the Cuban doctors</h2> In order to bypass Congress, the Dilma Rousseff administration decided to triangulate the business: the Brazilian government would pay the Pan-American Health Organization (PAHO), which would hire the Cuban Government, which, only then, would hire the doctors. In fact, when Cuban doctors sued in Brazil order to lift the restrictions imposed on them by Havana, the Brazilian government responded that it had no direct relationship with them. In October 2011, Cuba created private companies with government ties. One of them was Comercializadora de Servicios Médicos Cubanos (CSMC), which exported medical workers and supplies. Medical services are one of the main components of Cuba’s foreign trade agenda, with agreements in more than 60 countries. Five months later, in March 2012, a CSMC delegation prospected the Brazilian market. They visited the states of Amapá, Bahia, Paraíba, and the Federal District. On April 20, Tomás Reynoso, vice-president of the CSMC, offered the Brazilian embassy everything “from the sending of doctors and nurses to consult on the construction of hospitals, and the development of health systems,” at “advantageous prices,” according to Alexandre Ghisleni, at the time Brazil’s chargé d’affaires in Havana. <hr /> <h3>Municipalities where Cuban doctors were sent to</h3> <img loading="lazy" class="alignnone size-full wp-image-11819" src="https://brazilian.report/wp-content/uploads/2018/11/Screen-Shot-2018-11-21-at-18.36.54.png" alt="cuban doctors" width="678" height="598" srcset="https://cdn-statics.brazilian.report/wp-content/uploads/2018/11/Screen-Shot-2018-11-21-at-18.36.54.png 678w, https://cdn-statics.brazilian.report/wp-content/uploads/2018/11/Screen-Shot-2018-11-21-at-18.36.54-300x265.png 300w, https://cdn-statics.brazilian.report/wp-content/uploads/2018/11/Screen-Shot-2018-11-21-at-18.36.54-610x538.png 610w" sizes="(max-width: 678px) 100vw, 678px" /> <hr /> Cuba’s Deputy Minister of Health, Marcia Cobas, then visited Brazil. At an official meeting in May, at the Ministry of Development, she offered 1,000 doctors in 2012. She presented the vacancies for doctors in the Amazon, “with an initial salary of 14,000 reais,” due to a lack of interest among Brazilians. She spoke of the cooperation agreement signed under the government of President Fernando Henrique Cardoso and said that she would only forge a new alliance if Brazil prevented the doctors from staying in Brazil at the end of the program, as had happened with 400 professionals in the 1990s. In June the Brazilian Health Ministry organized a visit to Havana to discuss the issue. According to the Brazilian embassy in Cuba, the project was “initiated in a cautious manner, in the face of concern about the repercussions from the arrival of Cuban doctors in Brazil’s medical community.” The delegation was headed by Health Ministry Secretary Mozart Sales. Alberto Kleiman, then international advisor to the Ministry of Health, also participated. Today, Mr. Kleiman is the Director of International Relations and Partnerships at the PAHO. <h2>Not much of a negotiation</h2> The documents show that the Brazilian delegation accepted every one of Cuba’s demands and that the biggest hurdle was agreeing on salaries. Brazil and Cuba only agreed on the figure that each doctor would receive. “The Brazilian side proposed the amount of USD 4,000 (USD 3,000 for the Cuban government and USD 1,000 for the doctor),” the office reports regarding the meeting. “The Cuban side, in turn, said it expected to receive USD 8,000 per doctor, but later proposed USD 6,000 (USD 5,000 for the Cuban government and USD 1,000 for the doctor).” Cuban authorities demanded that all doctors’ evaluations be carried out in Cuba, and that Brazil restrict itself to “familiarizing doctors with the language, procedural and administrative practices, and legislation.” A draft of the contract, which does not appear in the documents obtained, but was discussed at the office of Ambassador José Eduardo Felício, stated that disagreements could only be settled by the “Cuban Court of International Commercial Arbitration, under its procedural rules, in the City of Havana, and in Spanish.” Brazil accepted all these points. The idea was to sign a commercial contract for the purchase of medical services and not an agreement between governments. According to Felicio, a formal agreement “may have to be submitted to the National Congress, where, incidentally, it would generate controversy.” In November, the Embassy noted that 20 Brazilians would go to Cuba to “give two-week courses to Cuban doctors on the Brazilian Health System and its organization.” On the eve of Minister Alexandre Padilha’s trip to Cuba, in December 2012, the program was already being called “Más Médicos,” More Doctors, in Spanish. Almost everything had been agreed, except for two points. One was the price. Cuba lowered its offer to $5,000 per month per doctor, but the Brazilian government did not want to pay more than $4,000. The second point was the legal framework. Without an agreement approved by the Brazilian National Congress, it would be difficult. It was precisely at this time that the PAHO intervened as an intermediary, “characterizing the contracting of services as cooperation in the medical sphere,” Mr. Ghisleni emphasized. Cuba did not like it at all: the funds would have to go through Washington, where the PAHO is headquartered. Mr. Padilha then proposed that the resources be transferred between the offices of the organization, without going through the US. <h2>The reaction in Brazil</h2> The first signs of the Más Médicos program in Brazil arrived at the beginning of 2013. In January, the leader of the Government in the National Congress, Senator Eduardo Braga, told mayors in the state of Amazonas that Ms. Rousseff would allow foreign doctors to work in the country by way of presidential decrees. In March, Mr. Padilha went on a popular Brazilian TV talk show and stated that foreign doctors could be hired. The reaction from medical agencies, as the telegram originally predicted, was swift. On April 4, 2013, representatives of the Federal Council of Medicine, the Brazilian Medical Association and the National Federation of Physicians went to Brasilia to protest these measures. According to the participants consulted for this report, Ms. Rousseff did not confirm nor deny any information. Mr. Padilha and Mozart Sales, who negotiated in Cuba, were both present. Back in Havana, on April 23, 2013, a meeting was held to finalize the contract, documented at the new office of the Brazilian Ministry of Foreign Affairs. Representatives from Brazil, Cuba and the PAHO participated. On this same evening, at a meeting with the National Association of Mayors, Ms. Rousseff defended the recruitment of foreign doctors to work in Brazil. Three days later, the first version of the 80th cooperation agreement between Brazil and PAHO, the basis of the More Doctors Program, would be signed, but without the official name, which would not appear until after July. Until December, hiring was still being discussed. At that time, at least on paper, the program was classified as an educational project.

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Marcelo Soares

Marcelo Soares is a Brazilian journalist specializing in data journalism and reader engagement.

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