The privatization of medical education in Brazil: trends and challenges.

BACKGROUND: Like other countries, Brazil is struggling with issues related to public policies designed to influence the distribution, establishment, supply and education of doctors. While the number of undergraduate medical schools and places available on medical schools has risen, the increase in the number of doctors in Brazil in recent decades has not benefitted the population homogeneously. The government has expanded the medical schools at the country's federal universities, while providing incentives for the creation of new undergraduate courses at private establishments. This article examines the trends and challenges of the privatization of medical education in Brazil. METHODS: This is a descriptive, cross-sectional study based on secondary data from official government databases on medical schools and courses and institutions offering such courses in Brazil. It takes into account the year when the medical schools received authorization to initiatte the activities, where they are situated, whether they are run by a public or private entity, how many places they offer, how many students they have enrolled, and their performance according to Ministry of Education evaluations. RESULTS: Brazil had 241 medical schools in 2014, offering a total of 20,340 places. The private higher education institutions are responsible for most of the enrolment of medical students nationally (54 %), especially in the southeast. However, enrolment in public institutions predominate more in the capitals than in other cities. Overal, the public medical schools performed better than the private schools in the last two National Exam of Students' (ENADE). CONCLUSION: The privatization of the teaching of medicine at undergraduate level in Brazil represents a great challenge: how to expand the number of places while assuring quality and democratic access to this form of education. Upon seeking to understand the configuration and trends in medical education in Brazil, it is hoped that this analysis may contribute to a broader research agenda in the future.

Human resources for mental health care: current situation and strategies for action.

A challenge faced by many countries is to provide adequate human resources for delivery of essential mental health interventions. The overwhelming worldwide shortage of human resources for mental health, particularly in low-income and middle-income countries, is well established. Here, we review the current state of human resources for mental health, needs, and strategies for action. At present, human resources for mental health in countries of low and middle income show a serious shortfall that is likely to grow unless effective steps are taken. Evidence suggests that mental health care can be delivered effectively in primary health-care settings, through community-based programmes and task-shifting approaches. Non-specialist health professionals, lay workers, affected individuals, and caregivers with brief training and appropriate supervision by mental health specialists are able to detect, diagnose, treat, and monitor individuals with mental disorders and reduce caregiver burden. We also discuss scale-up costs, human resources management, and leadership for mental health, particularly within the context of low-income and middle-income countries.

The mental health workforce gap in low- and middle-income countries: a needs-based approach.

OBJECTIVE: To estimate the shortage of mental health professionals in low- and middle-income countries (LMICs). METHODS: We used data from the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS) from 58 LMICs, country-specific information on the burden of various mental disorders and a hypothetical core service delivery package to estimate how many psychiatrists, nurses and psychosocial care providers would be needed to provide mental health care to the total population of the countries studied. We focused on the following eight problems, to which WHO has attached priority: depression, schizophrenia, psychoses other than schizophrenia, suicide, epilepsy, dementia, disorders related to the use of alcohol and illicit drugs, and paediatric mental disorders. FINDINGS: All low-income countries and 59% of the middle-income countries in our sample were found to have far fewer professionals than they need to deliver a core set of mental health interventions. The 58 LMICs sampled would need to increase their total mental health workforce by 239,000 full-time equivalent professionals to address the current shortage. CONCLUSION: Country-specific policies are needed to overcome the large shortage of mental health-care staff and services throughout LMICs.

Sub-national assessment of inequality trends in neonatal and child mortality in Brazil.

OBJECTIVE: Brazil's large socioeconomic inequalities together with the increase in neonatal mortality jeopardize the MDG-4 child mortality target by 2015. We measured inequality trends in neonatal and under five mortality across municipalities characterized by their socio-economic status in a period where major pro poor policies were implemented in Brazil to infer whether policies and interventions in newborn and child health have been successful in reaching the poor as well as the better off. METHODS: Using data from the 5,507 municipalities in 1991 and 2000, we developed accurate estimates of neonatal mortality at municipality level and used these data to investigate inequality trends in neonatal and under five mortality across municipalities characterized by socio-economic status. RESULTS: Child health policies and interventions have been more effective in reaching the better off than the worst off. Reduction of under five mortality at national level has been achieved by reducing the level of under five mortality among the better off. Poor municipalities suffer from worse newborn and child health than richer municipalities and the poor/rich gaps have increased. CONCLUSION: Our analysis highlights the importance of monitoring progress on MDGs at sub-national level and measuring inequality gaps to accurately target health and inter-sectoral policies. Further efforts are required to improve the measurement and monitoring of trends in neonatal and under five mortality at sub-national level, particularly in developing countries and countries with large socioeconomic inequalities.

Characteristics and trends in the expansion of private dental schools in Brazil.

OBJECTIVE: This article describes and analyses the characteristics of the expansion of private dental education in Brazil from 1996 to December 2018 and its relationships with public policies and the country's labour and education market in dentistry. METHOD: The study used an exploratory and descriptive quantitative approach involving standardised data-collection techniques from open-access secondary databases. RESULT: From 1996 to 2018 there was an overall increase of 315% in dental schools (582% in the private sector and 49% in the public sector). Brazil had 374 dental schools in December 2018, 307 of which were private and 67 of which were public. The 374 schools offered 47,192 admission places, 89% of which were private. In five states, dental education is 100% private, while in another 19 states the private supply exceeds 70% of the total. In the other three states this offer is between 40% and 67%. From 1996 to 2016, the private sector's share of dental school graduates was 66%. Women represented 73% of Brazilian dental-school graduates in 2016. CONCLUSION: Privatisation of dental education in Brazil raises challenges for the development of policies, planning, organisation of care, and structuring of the training process for dentists, as well as the dynamics of the labour market in the health system.

The health worker shortage in Africa: are enough physicians and nurses being trained?

OBJECTIVE: To estimate systematically the inflow and outflow of health workers in Africa and examine whether current levels of pre-service training in the region suffice to address this serious problem, taking into account population increases and attrition of health workers due to premature death, retirement, resignation and dismissal. METHODS: Data on the current numbers and types of health workers and outputs from training programmes are from the 2005 WHO health workforce and training institutions' surveys. Supplementary information on population estimates and mortality is from the United Nations Population Division and WHO databases, respectively, and information on worker attrition was obtained from the published literature. Because of shortages of data in some settings, the study was restricted to 12 countries in sub-Saharan Africa. FINDINGS: Our results suggest that the health workforce shortage in Africa is even more critical than previously estimated. In 10 of the 12 countries studied, current pre-service training is insufficient to maintain the existing density of health workers once all causes of attrition are taken into account. Even if attrition were limited to involuntary factors such as premature mortality, with current workforce training patterns it would take 36 years for physicians and 29 years for nurses and midwives to reach WHO's recent target of 2.28 professionals per 1000 population for the countries taken as a whole--and some countries would never reach it. CONCLUSION: Pre-service training needs to be expanded as well as combined with other measures to increase health worker inflow and reduce the rate of outflow.

Assessment of human resources for health using cross-national comparison of facility surveys in six countries.

BACKGROUND: Health facility assessments are being increasingly used to measure and monitor indicators of health workforce performance, but the global evidence base remains weak. Partly this is due to the wide variability in assessment methods and tools, hampering comparability across and within countries and over time. The World Health Organization coordinated a series of facility-based surveys using a common approach in six countries: Chad, Côte d'Ivoire, Jamaica, Mozambique, Sri Lanka and Zimbabwe. The objectives were twofold: to inform the development and monitoring of human resources for health (HRH) policy within the countries; and to test and validate the use of standardized facility-based human resources assessment tools across different contexts. METHODS: The survey methodology drew on harmonized questionnaires and guidelines for data collection and processing. In accordance with the survey's dual objectives, this paper presents both descriptive statistics on a number of policy-relevant indicators for monitoring and evaluation of HRH as well as a qualitative assessment of the usefulness of the data collection tool for comparative analyses. RESULTS: The findings revealed a large diversity in both the organization of health services delivery and, in particular, the distribution and activities of facility-based health workers across the sampled countries. At the same time, some commonalities were observed, including the importance of nursing and midwifery personnel in the skill mix and the greater tendency of physicians to engage in dual practice. While the use of standardized questionnaires offered the advantage of enhancing cross-national comparability of the results, some limitations were noted, especially in relation to the categories used for occupations and qualifications that did not necessarily conform to the country situation. CONCLUSION: With increasing experience in health facility assessments for HRH monitoring comes greater need to establish and promote best practices regarding methods and tools for their implementation, as well as dissemination and use of the results for evidence-informed decision-making. The overall findings of multi-country facility-based survey should help countries and partners develop greater capacity to identify and measure indicators of HRH performance via this approach, and eventually contribute to better understanding of health workforce dynamics at the national and international levels.

Forecasting the global shortage of physicians: an economic- and needs-based approach.

OBJECTIVE: Global achievements in health may be limited by critical shortages of health-care workers. To help guide workforce policy, we estimate the future demand for, need for and supply of physicians, by WHO region, to determine where likely shortages will occur by 2015, the target date of the Millennium Development Goals. METHODS: Using World Bank and WHO data on physicians per capita from 1980 to 2001 for 158 countries, we employ two modelling approaches for estimating the future global requirement for physicians. A needs-based model determines the number of physicians per capita required to achieve 80% coverage of live births by a skilled health-care attendant. In contrast, our economic model identifies the number of physicians per capita that are likely to be demanded, given each country's economic growth. These estimates are compared to the future supply of physicians projected by extrapolating the historical rate of increase in physicians per capita for each country. FINDINGS: By 2015, the global supply of physicians appears to be in balance with projected economic demand. Because our measure of need reflects the minimum level of workforce density required to provide a basic health service that is met in all but the least developed countries, the needs-based estimates predict a global surplus of physicians. However, on a regional basis, both models predict shortages for many countries in the WHO African Region in 2015, with some countries experiencing a needs-based shortage, a demand-based shortage, or both. CONCLUSION: The type of policy intervention needed to alleviate projected shortages, such as increasing health-care training or adopting measures to discourage migration, depends on the type of shortage projected.

The Portuguese contribution to the brain drain from Portuguese speaking African countries.

In the first part of this paper, a secondary analysis of multiple data sources was done to identify how many nurses, physicians, dentists, pharmacists and other health workers have migrated from the Portuguese speaking African countries (PSAC) to Portugal between 1998 and 2002. In the second part, the results of a 2003 questionnaire based survey of 45 nurses, from Guinea-Bissau, residing in Portugal are reported. Health professionals are increasing as a proportion of total immigrants into Portugal. Relatively to the countries' of origin population, the PSAC contribute the most with foreign health professionals to the Portuguese healthcare system. Our study of Guinea-Bissau nurses in Portugal replicates the results of other studies and suggests that the decision to emigrate is multiply determined. The implication for policy makers is that the causal complexity among factors spurring emigration makes that the marginal effect of policy reforms addressing one or more of the multiple determinants of emigration may be sufficient to retain some proportion of health professionals, even when other determinants of emigration are present. The situation observed is also indicative of the need of programs for social integration of these professionals.

Health workforce issues and the Global Fund to fight AIDS, Tuberculosis and Malaria: an analytical review.

Recent studies have shown evidence of a direct and positive causal link between the number of health workers and health outcomes. Several studies have identified an adequate health workforce as one of the key ingredients to achieving improved health outcomes. Global health initiatives are faced with human resources issues as a major, system-wide constraint. This article explores how the Global Fund addresses the challenges of a health workforce bottleneck to the successful implementation of priority disease programmes. Possibilities for investment in human resources in the Global Fund's policy documents and guidelines are reviewed. This is followed by an in-depth study of 35 Global Fund proposals from five African countries: Ethiopia, Ghana, Kenya, Malawi and Tanzania. The discussion presents specific human resources interventions that can be found in proposals. Finally, the comments on human resources interventions in the Global Fund's Technical Review Panel and the budget allocation for human resources for health were examined. Policy documents and guidelines of the Global Fund foster taking account of human resources constraints in recipient countries and interventions to address them. However, the review of actual proposals clearly shows that countries do not often take advantage of their opportunities and focus mainly on short-term, in-service training in their human resources components. The comments of the Technical Review Panel on proposed health system-strengthening interventions reveal a struggle between the Global Fund's goal to fight the three targeted diseases, on the one hand, and the need to strengthen health systems as a prerequisite for success, on the other. In realizing the opportunities the Global Fund provides for human resources interventions, countries should go beyond short-term objectives and link their activities to a long-term development of their human resources for health.

Addressing the health workforce crisis: towards a common approach.

The challenges in the health workforce are well known and clearly documented. What is not so clearly understood is how to address these issues in a comprehensive and integrated manner that will lead to solutions. This editorial presents--and invites comments on--a technical framework intended to raise awareness among donors and multisector organizations outside ministries of health and to guide planning and strategy development at the country level.

The practice of physicians and nurses in the Brazilian Family Health Programme - evidences of change in the delivery health care model.

The article analyzes the practice of physicians and nurses working on the Family Health Programme (Programa de Saúde da Família or PSF, in Portuguese). A questionnaire was used to assess the evidences of assimilation of the new values and care principles proposed by the programme. The results showed that a great number of professionals seem to have incorporated the practice of home visits, health education actions and planning of the teams' work agenda to their routine labour activities.

Addressing the health workforce crisis: towards a common approach.

The challenges in the health workforce are well known and clearly documented. What is not so clearly understood is how to address these issues in a comprehensive and integrated manner that will lead to solutions. This editorial presents--and invites comments on--a technical framework intended to raise awareness among donors and multisector organizations outside ministries of health and to guide planning and strategy development at the country level.

Uses of population census data for monitoring geographical imbalance in the health workforce: snapshots from three developing countries.

BACKGROUND: Imbalance in the distribution of human resources for health (HRH), eventually leading to inequities in health services delivery and population health outcomes, is an issue of social and political concern in many countries. However, the empirical evidence to support decision-making is often fragmented, and many standard data sources that can potentially produce statistics relevant to the issue remain underused, especially in developing countries. This study investigated the uses of demographic census data for monitoring geographical imbalance in the health workforce for three developing countries, as a basis for formulation of evidence-based health policy options. METHODS: Population-based indicators of geographical variations among HRH were extracted from census microdata samples for Kenya, Mexico and Viet Nam. Health workforce statistics were matched against international standards of occupational classification to control for cross-national comparability. Summary measures of inequality were calculated to monitor the distribution of health workers across spatial units and by occupational group. RESULTS: Strong inequalities were found in the geographical distribution of the health workforce in all three countries, with the highest densities of HRH tending to be found in the capital areas. Cross-national differences were found in the magnitude of distributional inequality according to occupational group, with health professionals most susceptible to inequitable distribution in Kenya and Viet Nam but less so in Mexico compared to their associate professional counterparts. Some discrepancies were suggested between mappings of occupational information from the raw data with the international system, especially for nursing and midwifery specializations. CONCLUSIONS: The problem of geographical imbalance among HRH across countries in the developing world holds important implications at the local, national and international levels, in terms of constraints for the effective deployment, management and retention of HRH, and ultimately for the equitable delivery of health services. A number of advantages were revealed of using census data in health research, notably the potential for producing detailed statistics on health workforce characteristics at the sub-national level. However, lack of consistency in the compilation and processing of occupational information over time and across countries continues to hamper comparative analyses for HRH policy monitoring and evaluation.

Public health workforce: challenges and policy issues.

This paper reviews the challenges facing the public health workforce in developing countries and the main policy issues that must be addressed in order to strengthen the public health workforce. The public health workforce is diverse and includes all those whose prime responsibility is the provision of core public health activities, irrespective of their organizational base. Although the public health workforce is central to the performance of health systems, very little is known about its composition, training or performance. The key policy question is: Should governments invest more in building and supporting the public health workforce and infrastructure to ensure the more effective functioning of health systems? Other questions concern: the nature of the public health workforce, including its size, composition, skills, training needs, current functions and performance; the appropriate roles of the workforce; and how the workforce can be strengthened to support new approaches to priority health problems.The available evidence to shed light on these policy issues is limited. The World Health Organization is supporting the development of evidence to inform discussion on the best approaches to strengthening public health capacity in developing countries. WHO's priorities are to build an evidence base on the size and structure of the public health workforce, beginning with ongoing data collection activities, and to map the current public health training programmes in developing countries and in Central and Eastern Europe. Other steps will include developing a consensus on the desired functions and activities of the public health workforce and developing a framework and methods for assisting countries to assess and enhance the performance of public health training institutions and of the public health workforce.

Imbalance in the health workforce.

Imbalance in the health workforce is a major concern in both developed and developing countries. It is a complex issue that encompasses a wide range of possible situations. This paper aims to contribute not only to a better understanding of the issues related to imbalance through a critical review of its definition and nature, but also to the development of an analytical framework. The framework emphasizes the number and types of factors affecting health workforce imbalances, and facilitates the development of policy tools and their assessment. Moreover, to facilitate comparisons between health workforce imbalances, a typology of imbalances is proposed that differentiates between profession/specialty imbalances, geographical imbalances, institutional and services imbalances and gender imbalances.

Assessing human resources for health: what can be learned from labour force surveys?

BACKGROUND: Human resources are an essential element of a health system's inputs, and yet there is a huge disparity among countries in how human resource policies and strategies are developed and implemented. The analysis of the impacts of services on population health and well-being attracts more interest than analysis of the situation of the workforce in this area. This article presents an international comparison of the health workforce in terms of skill mix, sociodemographics and other labour force characteristics, in order to establish an evidence base for monitoring and evaluation of human resources for health. METHODS: Profiles of the health workforce are drawn for 18 countries with developed market and transitional economies, using data from labour force and income surveys compiled by the Luxembourg Income Study between 1989 and 1997. Further descriptive analyses of the health workforce are conducted for selected countries for which more detailed occupational information was available. RESULTS: Considerable cross-national variations were observed in terms of the share of the health workforce in the total labour market, with little discernible pattern by geographical region or type of economy. Increases in the share were found among most countries for which time-trend data were available. Large gender imbalances were often seen in terms of occupational distribution and earnings. In some cases, health professionals, especially physicians, were overrepresented among the foreign-born compared to the total labour force. CONCLUSIONS: While differences across countries in the profile of the health workforce can be linked to the history and role of the health sector, at the same time some common patterns emerge, notably a growing trend of health occupations in the labour market. The evidence also suggests that gender inequity in the workforce remains an important shortcoming of many health systems. Certain unexpected patterns of occupational distribution and educational attainment were found that may be attributable to differences in health care delivery and education systems; however, definitional inconsistencies in the classification of health occupations across surveys were also apparent.

The role of wages in the migration of health care professionals from developing countries.

Several countries are increasingly relying on immigration as a means of coping with domestic shortages of health care professionals. This trend has led to concerns that in many of the source countries - especially within Africa - the outflow of health care professionals is adversely affecting the health care system. This paper examines the role of wages in the migration decision and discusses the likely effect of wage increases in source countries in slowing migration flows.This paper uses data on wage differentials in the health care sector between source country and receiving country (adjusted for purchasing power parity) to test the hypothesis that larger wage differentials lead to a larger supply of health care migrants. Differences in other important factors affecting migration are discussed and, where available, data are presented.There is little correlation between the supply of health care migrants and the size of the wage differential between source and destination country. In cases where data are available on other factors affecting migration, controlling for these factors does not affect the result.At current levels, wage differentials between source and destination country are so large that small increases in health care wages in source countries are unlikely to affect significantly the supply of health care migrants. The results suggest that non-wage instruments might be more effective in altering migration flows.

Developing evidence-based ethical policies on the migration of health workers: conceptual and practical challenges.

It is estimated that in 2000 almost 175 million people, or 2.9% of the world's population, were living outside their country of birth, compared to 100 million, or 1.8% of the total population, in 1995. As the global labour market strengthens, it is increasingly highly skilled professionals who are migrating. Medical practitioners and nurses represent a small proportion of highly skilled workers who migrate, but the loss of health human resources for developing countries can mean that the capacity of the health system to deliver health care equitably is compromised. However, data to support claims on both the extent and the impact of migration in developing countries is patchy and often anecdotal, based on limited databases with highly inconsistent categories of education and skills.The aim of this paper is to examine some key issues related to the international migration of health workers in order to better understand its impact and to find entry points to developing policy options with which migration can be managed.The paper is divided into six sections. In the first, the different types of migration are reviewed. Some global trends are depicted in the second section. Scarcity of data on health worker migration is one major challenge and this is addressed in section three, which reviews and discusses different data sources. The consequences of health worker migration and the financial flows associated with it are presented in section four and five, respectively. To illustrate the main issues addressed in the previous sections, a case study based mainly on the United Kingdom is presented in section six. This section includes a discussion on policies and ends by addressing the policy options from a broader perspective.