By Shasta Darlington and Letícia Casado

New York Times News Service

EMBU-GUAÇU, Brazil — The shiny plastic chairs all sat empty in a public health clinic, and the patients who staggered in were told to come back Thursday — now the only day when a doctor is there.

Embu-Guaçu, home to 70,000 people, recently lost 8 of its 18 public-sector doctors, forcing hard choices about who gets care and when.

“It’s heartbreaking,” said Fernanda Kimura, a doctor who coordinates the assignment of physicians for the local health department. “Like choosing which child to feed.”

Access to health care has been sharply curtailed for an estimated 28 million people across Brazil, according to the National Confederation of Municipalities, following a confrontation between Brazil’s new president, Jair Bolsonaro, and Cuba.

In November, Cuba announced it was recalling the 8,517 doctors it had deployed to Brazil, a response to the tough stance against Cuba that Bolsonaro had vowed to take when he was elected in October.

The abrupt departure has presented Bolsonaro with one of his first major policy challenges — and has tested his ability to deliver on a promise to find homegrown substitutions quickly.

But six months into his presidential term, which started in January, Brazil is struggling to replace the departed Cuban doctors with Brazilian ones: 3,847 public-sector medical positions in almost 3,000 municipalities remained unfilled as of April, according to the most recent figures available.

“In several states, health clinics and their patients don’t have doctors,” said Ligia Bahia, a professor at the Federal University of Rio de Janeiro. “It’s a step backward. It impedes early diagnoses, the monitoring of children, pregnancies and the continuation of treatments that were already underway.”

During his campaign, Bolsonaro, a right-wing populist, committed to changing the Mais Médicos program, an initiative begun in 2013 under a leftist government. The program sent doctors into Brazil’s small towns, indigenous villages and violent, low-income urban neighborhoods.

About half of the Mais Médicos doctors were from Cuba, and they were deployed to 34 remote indigenous villages and the poorer quarters of more than 4,000 towns and cities, places that established Brazilian physicians largely shun.

Brazil paid millions of dollars a month to Cuba for the doctors, making them a vital export for the island’s coffers.

But most of the money went directly to Cuba’s Communist government, an arrangement Bolsonaro warned he would change.

Cuban doctors have long complained about getting only a small cut of the money for their work, and Bolsonaro said they would have to keep their entire salaries and to bring their families with them to Brazil.

They would also have to pass equivalency exams to prove their qualifications.

Two weeks after Bolsonaro won the presidency, Cuba ordered all its doctors out.