Impacts of industrial actions, protests, strikes and lockouts by health and care workers during COVID-19 and other pandemic contexts: a systematic review.

BACKGROUND: Public health emergencies of international concern (PHEICs) as the COVID-19 pandemic and others that have occurred since the early 2000s put enormous pressure on health and care systems. This is being a context for protests by health and care workers (HCWs) because of additional workload, working conditions and effects on mental and physical health. In this paper, we intended to analyze the demands of HCWs associated with industrial actions, protests, strikes and lockouts (IAPSLs) which occurred during COVID-19 pandemic and other PHEICs; to identify the impact of these grievances; and describe the relevant interventions to address these IAPSLs. METHODS: We included studies published between January 2000 and March 2022 in PubMed, Embase, Scopus, BVS/LILACS, WHO's COVID-19 Research Database, ILO, OECD, HSRM, and Google Scholar for grey literature. Eligibility criteria were HCWs as participants, IAPSLs as phenomenon of interest occurring in the context of COVID-19 and other PHEICs. GRADE CERQual was used to assess risk of bias and confidence of evidence. RESULTS: 1656 records were retrieved, and 91 were selected for full-text screening. We included 18 publications. A system-wide approach, rather than a limited approach to institutions on strike, makes it possible to understand the full impact of the strike on health and care services. PHEICs tend to aggravate already adverse working conditions of HCWs, acting as drivers for HCWs strikes, leading to staff shortages, and financial issues, both in the North and in the Global South, particularly evident in Asia and Africa. In addition, issues related to deficiencies in leadership and governance in heath sector and lack of medical products and technologies (e.g., lack of personal protective equipment) were the main drivers of strikes, each contributing 25% of the total drivers identified. CONCLUSIONS: It is necessary to focus on the preparedness of health and care systems to respond adequately to PHEICs, and this includes being prepared for HCWs' IAPSLs, talked much in the context of COVID-19 pandemic. Evidence to assist policymakers in defining strategies to respond adequately to the health and care needs of the population during IAPSLs is crucial. The main impact of strikes is on the disruption of health care services' provision. Gender inequality being a major issue among HCWs, a proper understanding of the full impact of the strike on health and care services will only be possible if gender lens is combined with a systemic approach, rather than gender-undifferentiated approaches limited to the institutions on strike.

Impacts for health and care workers of Covid-19 and other public health emergencies of international concern: living systematic review, meta-analysis and policy recommendations.

BACKGROUND: Health and care workers (HCW) faced the double burden of the SARS-CoV-2 pandemic: as members of a society affected by a public health emergency and as HWC who experienced fear of becoming infected and of infecting others, stigma, violence, increased workloads, changes in scope of practice, among others. To understand the short and long-term impacts in terms of the COVID-19 pandemic and other public health emergencies of international concern (PHEICs) on HCW and relevant interventions to address them, we designed and conducted a living systematic review (LSR). METHODS: We reviewed literature retrieved from MEDLINE-PubMed, Embase, SCOPUS, LILACS, the World Health Organization COVID-19 database, the ClinicalTrials.org and the ILO database, published from January 2000 until December 2021. We included quantitative observational studies, experimental studies, quasi-experimental, mixed methods or qualitative studies; addressing mental, physical health and well-being and quality of life. The review targeted HCW; and interventions and exposures, implemented during the COVID-19 pandemic or other PHEICs. To assess the risk of bias of included studies, we used the Johanna Briggs Institute (JBI) Critical Appraisal Tools. Data were qualitatively synthetized using meta-aggregation and meta-analysis was performed to estimate pooled prevalence of some of the outcomes. RESULTS: The 1013 studies included in the review were mainly quantitative research, cross-sectional, with medium risk of bias/quality, addressing at least one of the following: mental health issue, violence, physical health and well-being, and quality of life. Additionally, interventions to address short- and long-term impact of PHEICs on HCW included in the review, although scarce, were mainly behavioral and individual oriented, aimed at improving mental health through the development of individual interventions. A lack of interventions addressing organizational or systemic bottlenecks was noted. DISCUSSION: PHEICs impacted the mental and physical health of HCW with the greatest toll on mental health. The impact PHEICs are intricate and complex. The review revealed the consequences for health and care service delivery, with increased unplanned absenteeism, service disruption and occupation turnover that subvert the capacity to answer to the PHEICs, specifically challenging the resilience of health systems.

Application of the workload indicators of staffing need method to calculate the size of the medical staff at a maternity hospital in the state of Bahia, Brazil.

BACKGROUND: Functioning health systems require a health workforce (HWF) that is qualified, available, equitably distributed, and accessible to the entire population as the basis for guaranteeing access to health. There is a global HWF crisis, manifested in Brazil by unequal distribution of healthcare personnel, particularly in rural areas, urban peripheries, and other hard-to-reach communities, posing a major obstacle to guaranteeing access to health systems and services. Based on the above, calculating the size and analyzing the workloads of the medical staff in the Obstetrics Department (OD) and Urgent Care Center (UCC) in a state maternity hospital is relevant for designing improvements in the work processes and future strategies for recruiting, selecting, and retaining these workers at the hospital, in turn favoring improvement in the quality of care for women and children at the state level. This scenario motivated the study's design, in which the overall objective was to analyze the workload of staff physicians working in the Obstetrics Department and Urgent Care Center of a public maternity hospital in the state of Bahia, based on the WISN method. METHODS: This was an exploratory-descriptive intervention study with a quantitative approach and qualitative elements, using the methodological stages recommended by the WISN to calculate and analyze the workload of obstetricians working in the OD and UCC in the maternity hospital. RESULTS: The study found a deficit of 14 shift obstetricians at the hospital with a workload of 0.81. The study also found that the insufficient number of obstetricians at the hospital resulted from precarious hiring formats, idle medical positions, and poorly structured work processes and a shortage in the multidisciplinary staff. CONCLUSION: The research sought to contribute to the reduction of the gap in models and methodologies for the staffing of gynecologists and obstetricians in Bahia Maternity Hospitals, without covering the whole subject, but to demonstrate that the findings of the workload analysis and its validation could be useful in promoting and directing the design and implementation of interventions to improve the quality of the workload.

[Financialization and oligopolization of private teaching institutions in Brazil: the case of medical schools]. / Financeirização e oligopolização das instituições privadas de ensino no Brasil: o caso das escolas médicas.

There is a global trend towards the private sector's growing participation in training healthcare professionals, influenced by public policies. In Brazil, private medical schools have developed and expanded with government financing, more recently with support from the More Doctors Program. The study aimed to describe and analyze movements in the corporate reconfiguration of the educational sector, with trends towards oligopolization and financialization related to the recent expansion of medical education in Brazil. An exploratory qualitative and quantitative approach was used, associated with various methodological strategies, to overcome the limitations in access to information, with data collection from open-access secondary databases. The private sector now accounts for 60% of the course supply and 69% of enrollment in medicine, 31% of which is supplied by ten educational groups. The groups studied here highlight the dynamic educational market, mechanisms of financialization and concentration, and formation of an oligopoly in the supply of higher education, particularly in medical training. There has been a trend towards concentration of the supply of institutions of higher learning since 2000. The largest groups employ similar management strategies, expansion of their market share, shareholder format, business diversification, and uptake of investors and financial capital. Government programs like the More Doctors Program helped expand and concentrate the private educational sector with government transfers or advance financing. The trend has been towards oligopolization and financialization.

O contexto do artigo é a tendência global de aumento da participação do setor privado na formação de profissionais de saúde fortemente influenciada por políticas públicas. No Brasil, os cursos médicos privados se desenvolveram e expandiram com financiamentos governamentais e, recentemente, com o apoio do Programa Mais Médicos. O objetivo foi descrever e analisar os movimentos de reconfiguração empresarial do setor educacional com tendências de oligopolização e financeirização relacionadas à expansão recente do Ensino Médico no Brasil. Realizou-se abordagem qualiquantitativa, exploratória e descritiva associada a várias estratégias metodológicas, a fim de superar as limitações de acesso às informações, com coleta de dados em bases secundárias de acesso público. O setor privado é responsável pela oferta de 60% dos cursos e de 69% das vagas de medicina, das quais cerca de 31% são ofertadas por dez grupos educacionais. Nos grupos estudados destacam-se: dinamicidade do mercado educacional; mecanismos de financeirização e concentração; formação de oligopólio na oferta de Ensino Superior, em particular da formação médica. Tendência de concentração da oferta em instituições de Ensino Superior privadas desde os anos 2000. Similaridade dos maiores grupos nas estratégias de gestão, ampliação da participação no mercado, conformação do quadro de sócios, diversificação dos negócios e captação de investidores e capital financeiro. Programas governamentais, como o Programa Mais Médicos, contribuíram para a expansão e tendência de concentração do setor educacional privado com repasses de recursos públicos ou antecipação dos recursos. Tendência à oligopolização e à financeirização.

Tendencia global de aumento de la participación del sector privado en la formación de profesionales de salud, fuertemente influenciada por políticas públicas. En Brasil, los cursos médicos privados se desarrollaron y expandieron con la financiación gubernamental y, recientemente, con el apoyo del Programa Más Médicos. El objetivo fue describir y analizar los movimientos de reconfiguración empresarial del sector educacional con tendencias de oligopolización y financiarización, relacionados con la expansión reciente de la enseñanza médica en Brasil. Abordaje cualicuantitativo, exploratorio y descriptivo, asociado a varias estrategias metodológicas, con el fin de superar las limitaciones de acceso a la información, con recogida de datos en bases secundarias de acceso público. El sector privado es responsable de la oferta de un 60% de los cursos y de un 69% de las plazas de medicina, de las cuales cerca de un 31% se ofertan por parte de diez grupos educacionales. En los grupos estudiados se destacan: dinamicidad del mercado educacional; mecanismos de financiarización y concentración; formación de oligopolio en la oferta de enseñanza superior, en particular de la formación médica. Tendencia de concentración de la oferta en instituciones de educación superior privados desde el año 2000. Similitud de los mayores grupos en las estrategias de gestión, ampliación de la participación en el mercado, conformación del esquema de socios, diversificación de los negocios, así como la captación de inversores y capital financiero. Programas gubernamentales, como el Programa Más Médicos, contribuyeron a la expansión y tendencia de concentración del sector educacional privado con la transferencia de recursos públicos o anticipación de los mismos. Tendencia a la oligopolización y la financiarización.

Higher education privatization in Nursing in Brazil: profile, challenges and trends.

OBJECTIVE: this study aims to analyze and characterize the movement of expansion of Nursing undergraduate courses in Brazil since the 1990s. The characteristics of this expansion are discussed, as well as the socio-political setting where such movement occurred, and the quality of education available based on the data collected. METHOD: this is a descriptive and cross-sectional study with a quali-quantitative approach, with the use of secondary databases. RESULTS: an accelerated and disordered growth of Nursing undergraduate courses was identified, as well as the number of vacancies, especially due to the participation of the private sector, especially since the year 2000. Geographical inequalities in the distribution of these courses and vacancies were also identified. CONCLUSION: the strong expansion of higher education in Nursing, along with other health professions, resulted in the strengthening of private higher education institutions associated with economic groups, regional concentration, as well as the excessive offer of distance learning without adequate evaluation of its quality or repercussions.

Metodologias para calcular os custos de um curso de graduação em Medicina: uma revisão de escopo / Scoping review of methods used to calculate the costs of an undergraduate medical course

RESUMO Introdução: Em julho de 2021, o Brasil tinha 373 cursos de Medicina autorizados pelo MEC, dos quais 229 de instituições privadas, com um valor médio de mensalidade de R$ 8.242,70. O grande volume de recursos envolvidos em mensalidades, bolsas e fomentos (Prouni, Fies etc.) justifica o esforço envolvido neste trabalho. Objetivo: A revisão visou identificar as metodologias de análise de custo de formação de médicos, classificando-as segundo categorias de nível de ensino e abrangência do custo. Método: A metodologia escolhida foi a revisão de escopo, dado que a produção na área de foco é irregular e com lacunas metodológicas. Resultado: As buscas em português e inglês resultaram na seleção de 24 textos, que foram agrupados em nove grupos, elaboradas a partir do foco de seus conteúdos combinados com os interesses da pesquisa. Conclusão: A inexistência de consenso metodológico e a busca por otimizar recursos e avaliar a eficácia do ensino reforçam a necessidade do desenvolvimento de metodologias de apuração de custos da graduação em Medicina.

ABSTRACT Introduction: Brazil had 373 medical courses authorized by the Ministry of Education in July 2021, with 229 being in private institutions and an average monthly tuition rate of R$8,242.70. The vast number of resources involved in tuition, scholarships, and grants (PROUNI, FIES, and so forth) justifies the effort required for this activity. Objective: The review sought to find approaches for analyzing the cost of training doctors, categorizing them according to the level of education and cost scope. Method: Given the irregularity and methodological inadequacies around interest, the chosen methodology was a scoping review. Result: The literature search in Portuguese and English yielded 24 articles, which were divided into nine categories depending on their content focus and the study interests. Conclusion: The lack of methodological agreement, as well as the pressure to optimize resources and evaluate educational efficacy, highlight the need for the development of methods to determine the costs of undergraduate medical education.

Factors that influence human resources for health policy formulation: a multiple case study in Brazil and Portugal. / Fatores que influenciaram o processo de formulação de políticas de recursos humanos em saúde no Brasil e em Portugal: estudo de caso múltiplo.

This study aims to analyze whether the process by which policies for human resources for health that aim to improve the geographic distribution of physicians have been informed by scientific evidence in Brazil and Portugal. This was a multiple case study on a decision-making process for human resources for health in Brazil and Portugal. The respective case studies were based on Brazil's More Doctors Program (Programa Mais Médicos - PMM) and Portugal's strategy of hiring foreign physicians through bilateral agreements, to work in the country's National Health Service (SNS). We interviewed 27 key actors in the policy-making process on the following topics: factors that influenced the policy decisions, actors that were expected to win or lose from the policy, and the scientific evidence and available data used in the policy-making, among others. The most evident factors appearing in the interviews as having influenced the PMM were: institutions; external factors (Presidential elections); group interests (e.g. physicians' professional associations), governments (Brazil and Cuba), international organizations, and civil society; and ideas (scientific evidence). The most frequently cited factors in Portugal were: institutions and interests of government (from Portugal and the countries involved in the bilateral agreements), civil society, and groups (physicians' professional associations). Contrary to the case study in Brazil, where the evidence was reported to having played an important role in the policy decisions, in Portugal, scientific evidence was not identified as contributing to the specific policy process.

O estudo objetiva analisar o processo em que as políticas de recursos humanos em saúde (RHS), que visam melhorar a distribuição geográfica dos médicos, são (ou não) informadas por evidência científica no Brasil e em Portugal. Foi realizado um estudo de caso-múltiplo sobre o processo de decisão das políticas de RHS no Brasil e em Portugal. Para compor os estudos de caso, as políticas escolhidas foram o Programa Mais Médicos (PMM) e a estratégia de contratação de médicos estrangeiros por acordos bilaterais para o trabalho no Serviço Nacional de Saúde (SNS) português. Foram entrevistados 27 atores-chave no processo de formulação das políticas em análise nos seguintes tópicos: fatores que influenciaram a formulação, atores que eram esperados ganhar ou perder, evidências científicas e os dados disponíveis utilizados para a formulação, entre outros. Os fatores mais evidentes identificados nas entrevistas como sendo influenciadores do PMM foram: Instituições; Fatores Externos (eleições presidenciais); Interesses de grupos (por exemplo, associações de profissionais médicos), governos (brasileiro e cubano), organização internacional e sociedade civil; e Ideias (evidência científica). Os fatores mais listados em Portugal foram: Instituições e Interesses dos governos (português e envolvidos nos acordos bilaterais), sociedade civil e grupos (associações de profissionais médicos). Ao contrário do que se verificou no estudo de caso do Brasil, em que reconhecidamente a evidência teve um papel importante na formulação da política em análise, em Portugal a evidência científica não foi identificada como contributo para a formulação da intervenção em estudo.

El estudio tiene por objetivo analizar el proceso en el que las políticas de recursos humanos en salud (RHS), que tienen como fin la mejora de la distribución geográfica de los médicos, son (o no) informadas por evidencias científicas en Brasil y en Portugal. Se trata de un estudio de caso-múltiple sobre el proceso de decisión de las políticas de RHS en Brasil y en Portugal. Para configurar los estudios de caso, las políticas elegidas fueron el Programa Más Médicos (PMM) y la estrategia de contratación de médicos extranjeros mediante acuerdos bilaterales para el trabajo en el Servicio Nacional de Salud (SNS) portugués. Se entrevistaron a 27 actores-clave en el proceso de formulación de las políticas en el análisis en los siguientes asuntos: factores que influenciaron la formulación, actores que se esperaba ganar o perder, evidencias científicas y datos disponibles utilizados para la formulación, entre otros. Los factores más evidentes, identificados en las entrevistas como de influencia en el PMM, fueron: instituciones; factores externos (elecciones presidenciales); intereses de grupos (por ejemplo, asociaciones de profesionales médicos), gobiernos (brasileño y cubano), organización internacional y sociedad civil; e ideas (evidencia científica). Los factores más registrados en Portugal fueron: instituciones e intereses de los gobiernos (como el portugués y los involucrados en los acuerdos bilaterales), sociedad civil y grupos (asociaciones de profesionales médicos). Al contrario de lo que se verificó en el estudio de caso de Brasil, donde se reconoció que la evidencia tuvo un papel importante en la formulación de la política en análisis, en Portugal la evidencia científica no fue identificada como una contribución para la formulación de la intervención en estudio.

Financeirização e oligopolização das instituições privadas de ensino no Brasil: o caso das escolas médicas / Financialization and oligopolization of private teaching institutions in Brazil: the case of medical schools / Financiarización y oligopolización de las instituciones privadas de enseñanza en Brasil: el caso de las escuelas médicas

O contexto do artigo é a tendência global de aumento da participação do setor privado na formação de profissionais de saúde fortemente influenciada por políticas públicas. No Brasil, os cursos médicos privados se desenvolveram e expandiram com financiamentos governamentais e, recentemente, com o apoio do Programa Mais Médicos. O objetivo foi descrever e analisar os movimentos de reconfiguração empresarial do setor educacional com tendências de oligopolização e financeirização relacionadas à expansão recente do Ensino Médico no Brasil. Realizou-se abordagem qualiquantitativa, exploratória e descritiva associada a várias estratégias metodológicas, a fim de superar as limitações de acesso às informações, com coleta de dados em bases secundárias de acesso público. O setor privado é responsável pela oferta de 60% dos cursos e de 69% das vagas de medicina, das quais cerca de 31% são ofertadas por dez grupos educacionais. Nos grupos estudados destacam-se: dinamicidade do mercado educacional; mecanismos de financeirização e concentração; formação de oligopólio na oferta de Ensino Superior, em particular da formação médica. Tendência de concentração da oferta em instituições de Ensino Superior privadas desde os anos 2000. Similaridade dos maiores grupos nas estratégias de gestão, ampliação da participação no mercado, conformação do quadro de sócios, diversificação dos negócios e captação de investidores e capital financeiro. Programas governamentais, como o Programa Mais Médicos, contribuíram para a expansão e tendência de concentração do setor educacional privado com repasses de recursos públicos ou antecipação dos recursos. Tendência à oligopolização e à financeirização.

There is a global trend towards the private sector's growing participation in training healthcare professionals, influenced by public policies. In Brazil, private medical schools have developed and expanded with government financing, more recently with support from the More Doctors Program. The study aimed to describe and analyze movements in the corporate reconfiguration of the educational sector, with trends towards oligopolization and financialization related to the recent expansion of medical education in Brazil. An exploratory qualitative and quantitative approach was used, associated with various methodological strategies, to overcome the limitations in access to information, with data collection from open-access secondary databases. The private sector now accounts for 60% of the course supply and 69% of enrollment in medicine, 31% of which is supplied by ten educational groups. The groups studied here highlight the dynamic educational market, mechanisms of financialization and concentration, and formation of an oligopoly in the supply of higher education, particularly in medical training. There has been a trend towards concentration of the supply of institutions of higher learning since 2000. The largest groups employ similar management strategies, expansion of their market share, shareholder format, business diversification, and uptake of investors and financial capital. Government programs like the More Doctors Program helped expand and concentrate the private educational sector with government transfers or advance financing. The trend has been towards oligopolization and financialization.

Tendencia global de aumento de la participación del sector privado en la formación de profesionales de salud, fuertemente influenciada por políticas públicas. En Brasil, los cursos médicos privados se desarrollaron y expandieron con la financiación gubernamental y, recientemente, con el apoyo del Programa Más Médicos. El objetivo fue describir y analizar los movimientos de reconfiguración empresarial del sector educacional con tendencias de oligopolización y financiarización, relacionados con la expansión reciente de la enseñanza médica en Brasil. Abordaje cualicuantitativo, exploratorio y descriptivo, asociado a varias estrategias metodológicas, con el fin de superar las limitaciones de acceso a la información, con recogida de datos en bases secundarias de acceso público. El sector privado es responsable de la oferta de un 60% de los cursos y de un 69% de las plazas de medicina, de las cuales cerca de un 31% se ofertan por parte de diez grupos educacionales. En los grupos estudiados se destacan: dinamicidad del mercado educacional; mecanismos de financiarización y concentración; formación de oligopolio en la oferta de enseñanza superior, en particular de la formación médica. Tendencia de concentración de la oferta en instituciones de educación superior privados desde el año 2000. Similitud de los mayores grupos en las estrategias de gestión, ampliación de la participación en el mercado, conformación del esquema de socios, diversificación de los negocios, así como la captación de inversores y capital financiero. Programas gubernamentales, como el Programa Más Médicos, contribuyeron a la expansión y tendencia de concentración del sector educacional privado con la transferencia de recursos públicos o anticipación de los mismos. Tendencia a la oligopolización y la financiarización.

Human resources for health: global crisis and international cooperation. / Recursos humanos em saúde: crise global e cooperação internacional.

From the 1990s onwards, national economies became connected and globalized. Changes in the demographic and epidemiological profile of the population highlighted the need for further discussions and strategies on Human Resources for Health (HRH). The health workforce crisis is a worldwide phenomenon. It includes: difficulties in attracting and retaining health professionals to work in rural and remote areas, poor distribution and high turnover of health staff particularly physicians, poor training of health workforces in new sanitation and demographic conditions and the production of scientific evidence to support HRH decision making, policy management, programs and interventions. In this scenario, technical cooperation activities may contribute to the development of the countries involved, strengthening relationships and expanding exchanges as well as contributing to the production, dissemination and use of technical scientific knowledge and evidence and the training of workers and institutional strengthening. This article aims to explore this context highlighting the participation of Brazil in the international cooperation arena on HRH and emphasizing the role of the World Health Organization in confronting this crisis that limits the ability of countries and their health systems to improve the health and lives of their populations.

Challenges for ensuring availability and accessibility toin health care services under Brazil's Unified Health System (SUS). / Desafios para assegurar a disponibilidade e acessibilidade à assistência médica no Sistema Único de Saúde.

Shortages and imbalances in the distribution of the health workforce, are social and political problems that, along with the socio-economic inequality, reduce the access of the population to the health services. This study aims to understand the challenges of SUS policy-makers and managers to ensure the availability and geographical accessibility to health service providers. The analysis was guided by a framework of the health labour market and health policy interventions. Two main problems have been identified: shortage of doctors and maldistribution of professionals between levels of health care and between geographical areas. This review focused on eight interventions in the last 30 years, whose mainly aim was to correct the maldistribution of physicians in the SUS such as Rondon Project, Interiorization of Health Work Program, Medical Specialists Training Program, PHC Program and More Doctors Program. The discussion focuses on the factors that influence the outcome of these interventions.

Higher education privatization in Nursing in Brazil: profile, challenges and trends / A privatização do ensino superior em enfermagem no Brasil: perfil, desafios e tendências / Privatización de la educación superior en enfermería en Brasil: perfil, desafíos y tendencias

Objective: this study aims to analyze and characterize the movement of expansion of Nursing undergraduate courses in Brazil since the 1990s. The characteristics of this expansion are discussed, as well as the socio-political setting where such movement occurred, and the quality of education available based on the data collected. Method: this is a descriptive and cross-sectional study with a quali-quantitative approach, with the use of secondary databases. Results: an accelerated and disordered growth of Nursing undergraduate courses was identified, as well as the number of vacancies, especially due to the participation of the private sector, especially since the year 2000. Geographical inequalities in the distribution of these courses and vacancies were also identified. Conclusion: the strong expansion of higher education in Nursing, along with other health professions, resulted in the strengthening of private higher education institutions associated with economic groups, regional concentration, as well as the excessive offer of distance learning without adequate evaluation of its quality or repercussions.

Objetivo: o presente estudo visa analisar e caracterizar o movimento de expansão dos cursos de graduação de enfermagem no Brasil a partir dos anos 90. Discutem-se as características desta expansão, o cenário sócio-político em que ocorreu tal movimento, bem como a qualidade do ensino disponível com base nos dados coletados. Método: trata-se de um estudo descritivo, transversal e de abordagem quali-quantitativa, com o uso de bases de dados secundárias. Resultados: foi identificado um crescimento acelerado e desordenado dos cursos de graduação em enfermagem, bem como do número de vagas, devido especialmente à participação do setor privado, em especial a partir do ano 2000. Desigualdades geográficas na distribuição desses cursos e vagas também foram identificadas. Conclusão: a forte expansão do ensino superior em enfermagem, ao lado de outras profissões de saúde, resultou no fortalecimento de instituições privadas de ensino superior associadas a grupos econômicos, na concentração regional, bem como na oferta excessiva da modalidade de ensino a distância sem avaliação adequada de sua qualidade ou repercussões.

Objetivo: el presente estudio tiene como objetivo analizar y caracterizar el movimiento de expansión de las carreras de grado en enfermería en Brasil a partir de la década del 90. Se discuten las características de esta expansión, el escenario sociopolítico en el que ocurrió este movimiento, así como la calidad de la educación disponible según los datos recopilados. Método: se trata de un estudio descriptivo, transversal con enfoque cualitativo y cuantitativo, utilizando bases de datos secundarias. Resultados: se identificó un crecimiento acelerado y desordenado de las carreras de licenciatura en enfermería, así como el número de cupos, debido fundamentalmente a la participación del sector privado, especialmente a partir del año 2000. También se identificaron desigualdades geográficas en la distribución de las carreras y los cupos. Conclusión: la fuerte expansión de la educación superior en enfermería, junto con otras profesiones de la salud, favoreció el fortalecimiento de las instituciones privadas de educación superior asociadas a grupos económicos, la concentración regional y la oferta excesiva de educación a distancia sin la correcta evaluación de calidad o de las repercusiones.

Innovation, development, and financing of institutions of Higher Education in health.

The article analyzes the configuration and trends in institutions of Higher Education and their relationship as components of the Health Economic-Industrial Complex (HEIC). The expansion of higher education is part of the transition from elite to mass systems, with tensions between quantitative and qualitative aspects. Such changes reflect different cultures and are related to international phenomena such as globalization, economic transformations, the development of new information and communication technologies, and the emergence of an international knowledge network. The scale and content of these changes vary according to the expansion and institutional reconfiguration of educational systems, as well as the link between state and society. Market expansion for private higher education stirs competition, shapes business clusters, modifies training processes, and raises new public policy challenges. Resumo: Este artigo analisa a configuração e as tendências das instituições de Ensino Superior de saúde no seu relacionamento enquanto componentes do Complexo Econômico Industrial da Saúde (CEIS). A expansão do Ensino Superior é parte da transição de sistemas de elite para sistemas de massa, com tensionamentos entre aspectos quantitativos e qualitativos. Essas mudanças refletem diferentes culturas e se relacionam com fenômenos de escopo mundial como globalização, transformações econômicas, desenvolvimento de novas tecnologias de comunicação e informação, e emergência de uma rede internacional de conhecimento. A escala e o conteúdo dessas mudanças variam com a ampliação dos sistemas de ensino e na reconfiguração institucional, bem como na articulação entre Estado e sociedade. A ampliação do mercado privado no ensino acirra a competitividade, conformando conglomerados empresariais, alterando processos de formação e forjando novos desafios para as políticas públicas.

Reasons for choosing the profession and profile of newly qualified physicians in Brazil.

OBJECTIVE: To evaluate the socio-demographic profile, path to medical school admission and factors affecting the choice of becoming a physician in Brazil. METHOD: Application of a structured questionnaire to 4,601 participants among the 16,323 physicians who graduated between 2014 and 2015 that subsequently registered with one of the 27 Regional Boards of Medicine (CRMs). RESULTS: The average age of participants is 27 years, 77.2% are white, 57% come from families with a monthly income greater than ten times the minimum wage, 65% have fathers who have completed higher education, 79.1% attended a private high school, and 63.5% selected the "will to make a difference in people's lives or do good" as their main reason for choosing medicine, with some differences between the sexes and matriculation at a public or private medical school. CONCLUSION: The recent politics for educational diversity and the opening of additional medical schools has not yet had an impact on the socio-demographic profile of graduates, who are mainly white, wealthy individuals.

A participação de instituições de ensino superior privadas na formação em saúde no brasil / The participation of private higher education institutions in health training in brazil / La participación de instituciones de enseñanza superior privadas en la formación en salud en brasil

Resumo O ensino superior brasileiro, historicamente, é marcado pela presença de instituições privadas. Durante a franca expansão ocorrida nas duas últimas décadas, o setor privado apresentou um crescimento no número de matrículas e no percentual de participação. Este artigo descreve a participação privada nas graduações da saúde no período entre 1993 e 2013. A revisão bibliográfica sobre o ensino superior brasileiro e a análise descritiva de dados secundários evidenciaram que a participação do setor privado na formação em saúde, em muitos aspectos, tem sido compatível com a dinâmica do setor de ensino superior. Na década de 1990, o crescimento do setor privado foi tendência em todas as graduações em saúde, e na maior parte dos cursos as taxas de crescimento foram maiores que a média nacional. No período entre 2003 e 2013, os cursos de Medicina, Odontologia e Serviço Social apresentaram taxas de crescimento maiores que no período anterior e os demais apresentaram uma desaceleração das taxas de crescimento; já nos cursos de Biologia, Fonoaudiologia e Terapia Ocupacional, observou-se uma redução do número de matrículas em instituições privadas.

Abstract Brazilian higher education has been historically marked by the presence of private institutions. During the unhindered expansion that took place over the past two decades, the private sector presented a growth in the number of enrollments and in the percentage of participation. This article describes the private participation in the undergraduate courses in health in the period between 1993 and 2013. The review of the literature on Brazilian higher education and the descriptive analysis of the secondary data evinced that the participation of the private sector in the training in health, in many aspects, has been compatible with the dynamics of the higher education sector. In the 1990s, the growth of the private sector was a trend in all undergraduate courses in health, and, in most courses, the growth rates were higher than the national average. In the period between 2003 and 2013, the courses of Medicine, Odontology and Social Services presented growth rates that were higher than those of the preceding period, and the other courses presented a decrease in the growth rates; as for the courses of Biology, Speech and Language Therapy and Occupational Therapy, a decrease in the number of enrollments in private institutions was observed.

Resumen La enseñanza superior brasileña, históricamente, está marcado por la presencia de instituciones privadas. Durante la gran expansión producida en las últimas dos décadas el sector privado presentó un crecimiento en el número de matrículas y en el porcentaje de participación. Este artículo describe la participación privada en las titulaciones en salud en el período entre 1993 y 2013. La revisión bibliográfica sobre la enseñanza superior brasileña y el análisis descriptivo de datos secundarios ponen de manifiesto que la participación del sector privado en la formación en salud, en muchos aspectos, ha sido compatible con la dinámica del sector de enseñanza superior. En la década de 1990, el crecimiento del sector privado fue una tendencia en todas las licenciaturas en salud y en la mayor parte de las carreras las tasas de crecimiento fueron mayores que el promedio nacional. En el período entre 2003 y 2013, las carreras de Medicina, Odontología y Servicio Social presentaron tasas de crecimiento mayores que en el período anterior y las restantes presentaron una desaceleración de las tasas de crecimiento; ya en las carreras de Biología, Fonoaudiología y Terapia Ocupacional, se observó una reducción del número de matrículas en instituciones privadas.

Fatores que influenciaram o processo de formulação de políticas de recursos humanos em saúde no Brasil e em Portugal: estudo de caso múltiplo / Factores que influenciaron el proceso de formulación de políticas de recursos humanos en salud en Brasil y Portugal: estudio de caso múltiple / Factors that influence human resources for health policy formulation: a multiple case study in Brazil and Portugal

O estudo objetiva analisar o processo em que as políticas de recursos humanos em saúde (RHS), que visam melhorar a distribuição geográfica dos médicos, são (ou não) informadas por evidência científica no Brasil e em Portugal. Foi realizado um estudo de caso-múltiplo sobre o processo de decisão das políticas de RHS no Brasil e em Portugal. Para compor os estudos de caso, as políticas escolhidas foram o Programa Mais Médicos (PMM) e a estratégia de contratação de médicos estrangeiros por acordos bilaterais para o trabalho no Serviço Nacional de Saúde (SNS) português. Foram entrevistados 27 atores-chave no processo de formulação das políticas em análise nos seguintes tópicos: fatores que influenciaram a formulação, atores que eram esperados ganhar ou perder, evidências científicas e os dados disponíveis utilizados para a formulação, entre outros. Os fatores mais evidentes identificados nas entrevistas como sendo influenciadores do PMM foram: Instituições; Fatores Externos (eleições presidenciais); Interesses de grupos (por exemplo, associações de profissionais médicos), governos (brasileiro e cubano), organização internacional e sociedade civil; e Ideias (evidência científica). Os fatores mais listados em Portugal foram: Instituições e Interesses dos governos (português e envolvidos nos acordos bilaterais), sociedade civil e grupos (associações de profissionais médicos). Ao contrário do que se verificou no estudo de caso do Brasil, em que reconhecidamente a evidência teve um papel importante na formulação da política em análise, em Portugal a evidência científica não foi identificada como contributo para a formulação da intervenção em estudo.(AU)

El estudio tiene por objetivo analizar el proceso en el que las políticas de recursos humanos en salud (RHS), que tienen como fin la mejora de la distribución geográfica de los médicos, son (o no) informadas por evidencias científicas en Brasil y en Portugal. Se trata de un estudio de caso-múltiple sobre el proceso de decisión de las políticas de RHS en Brasil y en Portugal. Para configurar los estudios de caso, las políticas elegidas fueron el Programa Más Médicos (PMM) y la estrategia de contratación de médicos extranjeros mediante acuerdos bilaterales para el trabajo en el Servicio Nacional de Salud (SNS) portugués. Se entrevistaron a 27 actores-clave en el proceso de formulación de las políticas en el análisis en los siguientes asuntos: factores que influenciaron la formulación, actores que se esperaba ganar o perder, evidencias científicas y datos disponibles utilizados para la formulación, entre otros. Los factores más evidentes, identificados en las entrevistas como de influencia en el PMM, fueron: instituciones; factores externos (elecciones presidenciales); intereses de grupos (por ejemplo, asociaciones de profesionales médicos), gobiernos (brasileño y cubano), organización internacional y sociedad civil; e ideas (evidencia científica). Los factores más registrados en Portugal fueron: instituciones e intereses de los gobiernos (como el portugués y los involucrados en los acuerdos bilaterales), sociedad civil y grupos (asociaciones de profesionales médicos). Al contrario de lo que se verificó en el estudio de caso de Brasil, donde se reconoció que la evidencia tuvo un papel importante en la formulación de la política en análisis, en Portugal la evidencia científica no fue identificada como una contribución para la formulación de la intervención en estudio.(AU)

This study aims to analyze whether the process by which policies for human resources for health that aim to improve the geographic distribution of physicians have been informed by scientific evidence in Brazil and Portugal. This was a multiple case study on a decision-making process for human resources for health in Brazil and Portugal. The respective case studies were based on Brazil's More Doctors Program (Programa Mais Médicos - PMM) and Portugal's strategy of hiring foreign physicians through bilateral agreements, to work in the country's National Health Service (SNS). We interviewed 27 key actors in the policy-making process on the following topics: factors that influenced the policy decisions, actors that were expected to win or lose from the policy, and the scientific evidence and available data used in the policy-making, among others. The most evident factors appearing in the interviews as having influenced the PMM were: institutions; external factors (Presidential elections); group interests (e.g. physicians' professional associations), governments (Brazil and Cuba), international organizations, and civil society; and ideas (scientific evidence). The most frequently cited factors in Portugal were: institutions and interests of government (from Portugal and the countries involved in the bilateral agreements), civil society, and groups (physicians' professional associations). Contrary to the case study in Brazil, where the evidence was reported to having played an important role in the policy decisions, in Portugal, scientific evidence was not identified as contributing to the specific policy process.(AU)

Internal migration of physicians who graduated in Brazil between 1980 and 2014

Background: The internal migration of physicians from one place to another in the same country can unbalance the supply and distribution of these professionals in national health systems. In addition to economic, social and demographic issues, there are individual and professional factors associated with a physician’s decision to migrate. In Brazil, there is an ongoing debate as to whether opening medicine programmes in the interior of the country can induce physicians to stay in these locations. This article examines the migration of physicians in Brazil based on the location of the medical schools from which they graduated. Methods: A cross-sectional design based on secondary data of 275,801 physicians registered in the Regional Councils of Medicine (Conselhos Regionais de Medicina-CRMs) who graduated between 1980 and 2014. The evaluated outcome was migration, which was defined as moving away from the state where they completed the medicine programme to another state where they currently work or live. Results: 57.3% of the physicians in the study migrated. The probability of migration ratio was greater in small grouped municipalities and lower in state capitals. 93.4% of the physicians who trained in schools located in cities with less than 100,000 inhabitants migrated. Fewer women (54.2%) migrated than men (60.0%). More than half of the physicians who graduated between 1980 and 2014 are in federative units different from the unit in which they graduated. Individual factors, such as age, gender, time of graduation and specialty, vary between the physicians who did or did not migrate. Conclusions: The probability of migration ratio was greater in small municipalities of the Southeast region and strong in the states of Tocantins, Acre and Santa Catarina. New studies are recommended to deepen understanding of the factors related to the internal migration and non-migration of physicians to improve human resource for health policies.

Desafios para assegurar a disponibilidade e acessibilidade à assistência médica no Sistema Único de Saúde / Challenges for ensuring availability and accessibility toin health care services under Brazil's Unified Health System (SUS)

A escassez e os desequilíbrios na distribuição da força de trabalho em saúde são problemas sociais e políticos que, juntamente com a desigualdade socioeconômica, reduzem o acesso da população aos serviços de saúde. Este estudo tem o objetivo de compreender os desafios dos formuladores de políticas e gestores do SUS para assegurar a disponibilidade e a acessibilidade geográfica aos serviços prestados pelos médicos. A análise foi orientada por um quadro de análise do mercado de trabalho e das intervenções políticas na saúde. Foram identificados dois problemas centrais: escassez de médicos e má distribuição de profissionais entre os níveis de cuidados de saúde e entre as zonas geográficas. Nesta revisão, o foco é sobre oito intervenções nos últimos 30 anos, cujo objetivo principal era corrigir a má distribuição dos médicos no SUS, nomeadamente: o Projeto Rondon, o Programa de Interiorização do Trabalho em Saúde (PITS), o Programa de Apoio à Formação de Médicos Especialistas em Áreas Estratégicas (Pró-Residência), o Programa de Valorização dos Profissionais da Atenção Básica (PROVAB), o Programa Mais Médicos, entre outras. A discussão focaliza nos fatores que influenciam o resultado dessas intervenções.(AU)

Shortages and imbalances in the distribution of the health workforce, are social and political problems that, along with the socio-economic inequality, reduce the access of the population to the health services. This study aims to understand the challenges of SUS policy-makers and managers to ensure the availability and geographical accessibility to health service providers. The analysis was guided by a framework of the health labour market and health policy interventions. Two main problems have been identified: shortage of doctors and maldistribution of professionals between levels of health care and between geographical areas. This review focused on eight interventions in the last 30 years, whose mainly aim was to correct the maldistribution of physicians in the SUS such as Rondon Project, Interiorization of Health Work Program, Medical Specialists Training Program, PHC Program and More Doctors Program. The discussion focuses on the factors that influence the outcome of these interventions.(AU)

Innovation, development, and financing of institutions of Higher Education in health / Innovación, desarrollo y financiación de las instituciones de Enseñanza Superior en salud / Inovação, desenvolvimento e financiamento das instituições de Ensino Superior em saúde

Abstract: The article analyzes the configuration and trends in institutions of Higher Education and their relationship as components of the Health Economic-Industrial Complex (HEIC). The expansion of higher education is part of the transition from elite to mass systems, with tensions between quantitative and qualitative aspects. Such changes reflect different cultures and are related to international phenomena such as globalization, economic transformations, the development of new information and communication technologies, and the emergence of an international knowledge network. The scale and content of these changes vary according to the expansion and institutional reconfiguration of educational systems, as well as the link between state and society. Market expansion for private higher education stirs competition, shapes business clusters, modifies training processes, and raises new public policy challenges.

Resumen: Este artículo analiza la configuración y las tendencias de las instituciones de Enseñanza Superior de salud, en su relación como componentes del Complejo Económico Industrial de la Salud (CEIS). La expansión de la enseñanza superior es parte de la transición de sistemas de élite hacia sistemas de masa, con tensiones entre aspectos cuantitativos y cualitativos. Estos cambios reflejan diferentes culturas y se relacionan con fenómenos de alcance mundial como: la globalización, transformaciones económicas, desarrollo de nuevas tecnologías de comunicación e información, y emergencia de una red internacional de conocimiento. La escala y el contenido de esos cambios varían con la ampliación de los sistemas de enseñanza y en la reconfiguración institucional, así como en la articulación entre Estado y sociedad. La ampliación del mercado privado en la enseñanza estimula la competitividad, conformando conglomerados empresariales, alterando procesos de formación y forjando nuevos desafíos para las políticas públicas.

Resumo: Este artigo analisa a configuração e as tendências das instituições de Ensino Superior de saúde no seu relacionamento enquanto componentes do Complexo Econômico Industrial da Saúde (CEIS). A expansão do Ensino Superior é parte da transição de sistemas de elite para sistemas de massa, com tensionamentos entre aspectos quantitativos e qualitativos. Essas mudanças refletem diferentes culturas e se relacionam com fenômenos de escopo mundial como globalização, transformações econômicas, desenvolvimento de novas tecnologias de comunicação e informação, e emergência de uma rede internacional de conhecimento. A escala e o conteúdo dessas mudanças variam com a ampliação dos sistemas de ensino e na reconfiguração institucional, bem como na articulação entre Estado e sociedade. A ampliação do mercado privado no ensino acirra a competitividade, conformando conglomerados empresariais, alterando processos de formação e forjando novos desafios para as políticas públicas.

Reasons for choosing the profession and profile of newly qualified physicians in Brazil / Motivos de escolha da profissão e perfil de médicos recém-graduados no Brasil

SUMMARY Objective To evaluate the socio-demographic profile, path to medical school admission and factors affecting the choice of becoming a physician in Brazil. Method Application of a structured questionnaire to 4,601 participants among the 16,323 physicians who graduated between 2014 and 2015 that subsequently registered with one of the 27 Regional Boards of Medicine (CRMs). Results The average age of participants is 27 years, 77.2% are white, 57% come from families with a monthly income greater than ten times the minimum wage, 65% have fathers who have completed higher education, 79.1% attended a private high school, and 63.5% selected the “will to make a difference in people’s lives or do good” as their main reason for choosing medicine, with some differences between the sexes and matriculation at a public or private medical school. Conclusion The recent politics for educational diversity and the opening of additional medical schools has not yet had an impact on the socio-demographic profile of graduates, who are mainly white, wealthy individuals.

RESUMO Objetivo traçar o perfil sócio-demográfico de recémgraduados em medicina no Brasil, a forma de ingresso na graduação e os motivos de escolha da profissão médica. Método aplicação de questionário estruturado em 4.601 participantes, dentre 16.323 médicos formados entre 2014 e 2015, que se registraram em um dos 27 Conselhos Regionais de Medicina (CRM), considerados a populaçãoalvo do estudo. Resultados a idade média dos recém-graduados é de 27 anos, 77,2% são brancos, 57% vêm de famílias com renda mensal acima de dez salários mínimos, 65% têm pais com educação superior, 79,1% cursaram ensino médio em escola particular e 63,5% apontaram a “vontade de fazer diferença na vida das pessoas ou fazer o bem” como principal razão para a escolha da medicina, com diferenças entre sexo e natureza pública ou privada da escola de graduação. Conclusão as políticas no Brasil de inclusão educacional e de abertura de escolas médicas ainda não tiveram impacto no perfil dos recém-formados em medicina, em sua maioria indivíduos brancos e de maior nível socioeconômico.