Continuity and change in human resources policies for health: lessons from Brazil

Abstract

Background: This paper reports on progress in implementing human resources for health (HRH) policies in Brazil, in the context of the implementation and expansion of the Unified Health System (Sistema Unico de Saúde - SUS).The three main objectives were: i) to reconstruct the chronology of long term HRH change in Brazil, and to identify and discuss the precursors, drivers, and enablers for these changes over a long time period; (ii) to examine how change was achieved by describing facilitators and constraints, and how policies were adapted to deal with the latter; and (iii) to report on the current situation and draw policy implications.

Methods: A mixed methods approach was used. A literature review was conducted using pre-defined keywords; and stakeholders were contacted and asked to provide relevant information, data and policy reports.

Results: There are two key features of HRH change which are related to the implementation of SUS which merit attention: the achievement of staffing growth, and the improvement in HRH policy making and management. Staff growth rates across the period have been high enough to exceed population growth rates. As a consequence, the ratio of staff to population has improved. In 1990 the physician ratio per 1000 inhabitants was 1.12. In 2007, it was 1.74. Another critical factor in achieving staffing growth has been HRH policy making capacity and influence within the political establishment.

Conclusions: Policies have had to adapt to changing circumstances, whilst focusing on sequential improvements aimed at achieving long term goals. The end objectives, of improving care and access to care, have been kept in view. No one Ministry could secure all the resources and impetus for change that has been required, hence the need for inter-ministry, inter-governmental and inter-agency collaboration, and the development of alliances of shared interest. Across the period of thirty years or more, not all initiatives have been equally successful, but a momentum has been maintained. There was no single long term plan or strategy, but in Brazil this has enabled the progress to be adapted and re-oriented as the broader context changed over the years.

Figure 1

Number of health facilities in Brazil since 1976 to 2005: total, private and public. Note: (1) does not include diagnostic services Source: Instituto Brasileiro de Geografia e Estatística (IGBE)[18] Note: not sequential years

Figure 2

Evolution of HRH ratios per 1000 inhabitants, from 1990 to 2007, per occupation. Source: Instituto Brasileiro de Geografia e Estatística, (IGBE)[18]

Figure 3

Organigram of the MoH and Secretariat of Labor and Education Management in Health. Source: adapted from [4]

Figure 4

Schematic representation of the implementation of HRH elements of SUS. Source: authors