Abstract

This study analyzes the production of scientific knowledge on Health Inequalities (HI) and its use in policies of education of dentists, nurses and physicians in Brazil and Portugal. Documents published between January 2000 and December 2001, in Portuguese, French, English and Spanish, were identified by means of a combination of a manual and intentional electronic database survey of the grey literature. Fifty-three documents were selected from a total of 1,652. The findings revealed that there is still little knowledge available to enable an assessment of policies for human resource training in healthcare in general and for those related to physicians, nurses and dentists in particular. In Brazil, few studies have thus far been made to understand how such training can contribute towards reducing these inequalities and, in the case of Portugal, no studies were found that established a direct relationship between human resource training and the future role that these could play in combating inequality. Despite a vast increase in scientific production, many lacunae still exist in this field. Knowledge production and its relationship with decision-making still seem to be separate processes in these two countries.

Key words
Evidence-based policies; Social inequalities in health; Training; Human resources in health (HRH); Health policy

Introduction

Despite improvements in health determinants, social inequalities are still a major problem in public health¹1. Graham H. Social determinants and their unequal distribution: clarifying policy understandings. Milbank Q 2004; 82(1):101-124.–³3. Whitehead M, Dahlgren G. European strategies for tackling social inequities in health: leveling up part 2. Studies on social and economic determinants of population health, N° 3. Copenhagen: WHO Regional Office for Europe; 2007. [acessado 2012 dez 1]. Disponível em: http://www.euro.who.int/document/e89384.pdf
http://www.euro.who.int/document/e89384.... . In many European countries, including Portugal, several health indicators, such as life expectancy and infant mortality, have shown improvements during recent decades; however, considerable challenges still exist in relation to geographic variations between social groups and minorities and the care required for an aging population⁴4. Mackenbach JP, Karanikolos M, McKee M. The unequal health of Europeans: successes and failures of policies. Lancet 2013; 381(9872):1073-1074.,⁵5. OECD. Health at a Glance. Indicators. OECD; 2011. [acessado 2014 nov 1]. Disponível em: http://www.oecd.org/els/health-systems/49105858.pdf
http://www.oecd.org/els/health-systems/4... . In the case of Brazil, although improvements have been seen during recent years, regional, geographic and social inequalities remain unchanged for mortality and morbidity rates⁶6. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. O sistema de saúde brasileiro: história, avanços e desafios. Lancet 2011. [acessado 2013 fev 1]. Disponível em: http://download.thelancet.com/fatcontentassets/pdfs/brazil/brazilpor1.pdf
http://download.thelancet.com/fatcontent... . In order to respond to these, the health systems need to make improvements in terms of effectiveness, efficiency and equity⁷7. Mccarthy M, Harvey G, Conceição C, La Torre G, Gulis G. Comparing public-health research priorities in Europe. Health Research Policy and Systems 2009; 7:17. [acessado 2012 out 1]. Disponível em: http://www.health-policy-systems.com/content/7/1/17
http://www.health-policy-systems.com/con... .

In order to achieve equity of access and the use of health services, the health systems should be organized in such a way as to reduce barriers of access to the population as a whole⁸8. Travassos C, Castro MSM. Determinantes e desigualdades sociais no acesso e na utilização de serviços de saúde. In: Giovanella L, Escorel S, Lobato LVC, Noronha J C, Carvalho AI, organizadores. Políticas e Sistema de Saúde no Brasil.Rio de Janeiro: Editora Fiocruz; 2008. p. 215-243., and Human Resources in Health (HRH) are seen as one of the essential pillars to attain this objective⁹9. World Health Organization (WHO). Everybody business: strengthening health systems to improve health outcomes. Geneva: WHO framework for action; 2007.,¹⁰10. Rigoli F, Dussault G. The interface between health sector reform and human resources. Human Resources for Health 2003; 1:9. [acessado 2012 out 1]. Disponível em: http://www.human-resources-health.com/content /1/1/9
http://www.human-resources-health.com/co... .

There has been an increase in scientific publications in the area of social inequality, which brings to the fore the question of how they are used to form health policies and, in particular, for HRH training, employability and management, bearing in mind the contribution this has made to help strengthen the health system and to provide equal access to its services¹¹11. Levesque JF, Harris M, Russell G. Patient-centred access to health care: conceptualizing access at the interface of health systems and populations. Int J Equity Health 2013; 12:18.. Ultimately, this production can be used to meet the objectives outlined in the Universal Health Coverage adopted by member states of the United Nations in 2012¹²12. United Nations General Assembly. Global health and foreign policy. 67th session, New York: United Nations; 2012. (Agenda item 123. A/67/L.36). and supported by its agencies, principally by the World Health Organization (WHO)¹³13. World Health Organization (WHO). Universal health coverage. Geneva: WHO; 2013. [acessado 2013 jun 1] Disponível em: http://www.who.int/universal_heal-th _coverage/en
http://www.who.int/universal_heal-th_cov... .

Several authors note the need to undertake studies into the evolution of knowledge production, as well as ways to use this and the impact that this knowledge will have when integrated into policies¹⁴14. Hanney SR, Gonzalez-Block MA, Buxton MJ, Kogan M. The utilization of health research in policy-making: concepts, examples and methods of assessment. Health Research Policy and System 2003; 1:2. [acessado 2012 fev 1]. Disponível em: http://www.health-policy-systems.com/content/1/1/2
http://www.health-policy-systems.com/con... ,¹⁵15. Hartz Z, Denis J, Moreira E, Matida A. From Knowledge to Action: Challenges and Opportunities for Increasing the Use and Evaluation in Health Promotion Policies and Practices. In: Potvin L, McQueen D, editors. Health Promotion Evaluation Practices in the Americas. Berlin: Springer Science Business Media; 2008.. They also recognize the relevance of integrating knowledge production related to social inequalities and their different (social, economic, cultural) determinants in health policy investigations and formulation agendas.

Thus, it is important to understand if advances have been made in using knowledge produced for the definition of health policies¹⁶16. Pellegrini Filho A. Pesquisa em saúde, política de saúde e equidade na América Latina. Cien Saude Colet 2004; 9(2):339-350., bearing in mind the growing need for decisions made by management, clinicians and policy makers to be based on solid scientific knowledge. We acknowledge that the process of elaborating health policies takes into account research findings¹⁷17. World Health Organization (WHO). Bulletin of the World Health Organization 2005. Geneva: WHO; 2005. December, 83(12).,¹⁸18. Council on Health Research for Development: 2012. [acessado 2012 fev 1]. Disponível em: http://www.cohred.org/sdh-net/
http://www.cohred.org/sdh-net/... , in spite of differences existing between researchers and decision-makers¹⁵15. Hartz Z, Denis J, Moreira E, Matida A. From Knowledge to Action: Challenges and Opportunities for Increasing the Use and Evaluation in Health Promotion Policies and Practices. In: Potvin L, McQueen D, editors. Health Promotion Evaluation Practices in the Americas. Berlin: Springer Science Business Media; 2008., in terms of the theoretical reference frameworks used to approach these issues. In addition, there is an inherent complexity involved in the interaction between research and policy-making, due to the nature of scientific information, very often plentiful, which is diversified and inaccessible to policy-makers¹⁹19. Brownson RC, Chriqui JF, Stamatakis KA. Understanding Evidence-Based Public Health Policy. Am J Public Health 2009; 99(9):1576-1583..

It is recognized that there is a lack of comparative studies used to review literature about how knowledge production is applied¹⁵15. Hartz Z, Denis J, Moreira E, Matida A. From Knowledge to Action: Challenges and Opportunities for Increasing the Use and Evaluation in Health Promotion Policies and Practices. In: Potvin L, McQueen D, editors. Health Promotion Evaluation Practices in the Americas. Berlin: Springer Science Business Media; 2008.. Understanding how the formulation of health policies can benefit from comparisons made between countries, shows the relevance of conducting transnational studies about how research findings are applied.

In order to make an analysis of issues that are of interest both to Portugal and Brazil, in view of their cultural similarities and language, we used a conceptual framework that made it easier to analyze the findings obtained in both countries. This article presents the findings of the first stage of a study aimed at analyzing the barriers and the facilitators for the use of knowledge produced, according to researchers and policy makers, who are the potential users of such knowledge. Naturally, further studies will be needed to identify factors that maintain barriers to disseminating knowledge about social inequalities and the potential this has to be used to formulate HRH training policies, which aim to reduce same.

Thus, the aim of this study is to analyze the production of scientific knowledge about social inequalities in health and to discuss its relationship with training policies for physicians, nurses and dentists in Brazil and Portugal.

Methods

Between October 2012 and January 2013, in accordance with Torraco²⁰20. Torraco RJ. Writing Integrative Literature Reviews: Guidelines and Examples. Human Resource Development Review 2005; 4(3):356-367., we undertook an integrative survey of the literature on social inequalities in healthcare and the training of physicians, nurses and dentists for the period between January 2000 and December 2012. This was done using open access electronic data bases from Pubmed/The National Library of Medicine/ Washington; the Pan-American Health Organization; the Virtual Health Library (BVS) via Bireme (consisting of the Latin American and Caribbean Literature - LILACS, Wholis, the WHO library database, The Cochrane Library, among others); the CAPES thesis database; the Network of HRH observatories in Brazil; the Brazilian Ministry of Health; the Portuguese Directorate-General of Health (DGS); the Health Portal of Portugal and Google Scholar - and other sources of restricted access (e.g. unpublished books, documents).

We used key words such as "human resources," "health," "health professionals," "physicians," "nurses," "dentists," "training policy," "intervention," "inequality" and "iniquities," and we researched these in combinations, separately, with an alteration to the ending of a word and in other languages, according to the specificity of each database. To analyze the documents, we divided the key words into two sections: scientific production in social inequalities in health and HRH trainingand health training policies and interventions.

For the first section, we sub-divided the documents as follows:

1. –

   Context – documents related to institutional issues (of the health system) and in the context of producing policies for graduate, post-graduate and ongoing training for professionals who are studying, and documents that explain the social context of producing knowledge and HRH training policies;

2. –

   Empirical studies – correspond to investigations that have been conducted with a presentation of their research findings. These include an extension of the problem, possible interventions and an assessment of training policies for professionals who are undertaking studies;

3. –

   Policies: documents published in the Official Government Gazette and reports identified as publications that support policies.

For the second section, we subdivided documents according to their type of approach to HRH training:

1. – documents that only mention or show the problem of social inequality in health;

2. – documents that mention or present and discuss the problem (adjusted, for example, for the context of the country, region, etc.);

3. – documents that present solutions or strategies or interventions in terms of training;

4. – documents that access HRH training policies;

When analyzing these documents, we considered four types of inequalities based on Therborn²¹21. Therborn G. Meaning, mechanisms, patterns, and forces: an introduction. In: Therborn G, editor. Inequalities of the world. New Theoretical Frameworks, Multiple Empirical Approaches. London: Verso; 2006. p. 1-58.:

• Economic – including the distribution of income and material resources;

• Social or living conditions – including gender, race, education, geographic location, vulnerable populations (migrants, immigrants and indigenous peoples);

• Institutional or the organization of health systems – including inequality in the regional distribution of HRH, the level of healthcare and access to and use of healthcare services;

• In comprehensive health – whenever authors present this in very broad terms, i.e., lacking sufficient information to enable a classification to be made, or when all types of inequalities mentioned above were included.

The inclusion criterion were: articles published between January 2000 and December 2012, in Portuguese, English, French and Spanish; on physicians, nurses and dentists; empirical and/or conceptual/theoretical works using the terms ‘inequality/social health determinants," or research where interventions in the area of the training of physicians, nurses and/or dentists, or health professionals in general, were covered by these policies. In view of the systemization of these studies we used the following concepts:

• Social inequalities in health – these are the systematic differences in the health situation of different population groups – social inequalities in health conditions and in access to and use of healthcare services illustrate differential opportunities resulting from a person's social position and which characterize situations of social injustice which represent iniquity⁸8. Travassos C, Castro MSM. Determinantes e desigualdades sociais no acesso e na utilização de serviços de saúde. In: Giovanella L, Escorel S, Lobato LVC, Noronha J C, Carvalho AI, organizadores. Políticas e Sistema de Saúde no Brasil.Rio de Janeiro: Editora Fiocruz; 2008. p. 215-243..

• Iniquities – this refers to inequalities in health which, as well as being systematic and relevant, are avoidable, unjust and unnecessary²²22. World Health Organization (WHO). Glossary of Terms.Geneva: WHO; 2013. [acessado 2013 dez 1] Disponível em: http://www.who.int/hia/about/glos/en/index1. html
  http://www.who.int/hia/about/glos/en/ind... ; these include inequalities in living conditions and income distribution²³23. Whitehead M, Petticrew M, Graham H, Macintyre S, Bambra C, Egan M. Evidence for public health policy on inequalities Paper II: assembling the evidence jigsaw. J Epidemiol Community Health 2004; 58(10):817-821..

• Social determinants of health (SDH) – are the social condition in which people live and work or "the social characteristics within which their lives are lived"²⁴24. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health 2003; 57(4):254-258..

In summary, so many social inequalities in health such as SDH represent inequalities in social groups who have more or less advantages, which place the former at a disadvantage. Equity cannot be assessed without the inclusion of this element of comparison between groups who receive greater and fewer benefits²⁵25. Tarlov A. Social determinants of health: the sociobiological translation. In: Blane D, Brunner E, Wilkinson R, editors. Health and social organization. London: Routledge; 1996. p. 71-93.. Social inequalities in health vary between different countries, in accordance with the way their health systems are organized. In this respect, the Commission for Social Determinants of Health (CSDH)²⁶26. Comissão para as Desigualdades Sociais em Saúde (CDSS). Redução das desigualdades no período de uma geração. Igualdade na saúde através da acção sobre os seus determinantes sociais. Relatório Final da Comissão para os Determinantes Sociais da Saúde. Lisboa: Organização Mundial da Saúde; 2010. considers that health systems represent one of the determinants of social inequality in health conditions, and play a relevant role in reducing these; although Travassos and Castro⁸8. Travassos C, Castro MSM. Determinantes e desigualdades sociais no acesso e na utilização de serviços de saúde. In: Giovanella L, Escorel S, Lobato LVC, Noronha J C, Carvalho AI, organizadores. Políticas e Sistema de Saúde no Brasil.Rio de Janeiro: Editora Fiocruz; 2008. p. 215-243. state that modifying the characteristics of the health system directly changes the social inequalities involved in access and use of such services, but are incapable in themselves of changing the social inequalities in health conditions that exist between different social groups.

"Health policy" refers to decisions, plans and actions employed to achieve a specific objective in health within a certain society and define a vision for the future, which helps establish short and medium-term goals, establish priorities and the roles attributed to different actors²⁷27. World Health Organization (WHO). Health Policy. Geneva: WHO; 2014. [acessado 2014 mar 1]. Disponível em: http://www.who.int/topics/health_policy/en/
http://www.who.int/topics/health_policy/... . These include laws, regulations, decree-laws, but also technical documents in support of policies¹⁹19. Brownson RC, Chriqui JF, Stamatakis KA. Understanding Evidence-Based Public Health Policy. Am J Public Health 2009; 99(9):1576-1583. and programs.

This may be understood as the formal side of health policy – the legal (the Federal Constitution, laws and executive actions), the institutional (Ministries, Secretariats and the Legislative), official statements (national health policy) and the actions of a group of individuals within society whose main task is to prepare laws and execute policies²⁸28. Mattos RA, Batista TWF, organizadores. Caminhos para a análise das políticas de saúde. Ed. Online. Rio de Janeiro: UERJ; 2011. [acessado 2013 jan 1]. Disponível em: http://www.ims.uerj.br/ccaps/wp-content/uploads/2011/10/LivroCompleto-versao-online.pdf
http://www.ims.uerj.br/ccaps/wp-content/... .

This study does not consider cases of "informal policies," namely citizen participation; and we understand the term "production of knowledge" as "the scientific production of knowledge"²⁹29. Assis M, Hartz ZMA, Pacheco LC, Victor VV. Avaliação do projeto de promoção da saúde do Núcleo de Atenção ao Idoso: um estudo exploratório. Comunicação Saúde Educação 2009; 13(29):367-382..

Results

Of the total of 1.652 documents found in the databases that we researched, fifty-three were selected. Of these, the majority (53%) are "contextual," followed by "empirical" (21%) and "policy" (26%) documents.

As regards the type of document selected, in the case of Brazil, most of these (25%) are articles, followed by Master's dissertations and doctoral thesis and policy documents. Documents related to legislation and technical reports supporting policies were found in equal numbers – 19%. In the case of Portugal, most of the documents relate to policy, that is, interventions by the Ministry of Health, the National Health Plan (PNS) and legislation (41%), followed by investigative reports (35%).

The institutions promoting most of the documents selected were universities (46%), followed by national organs (43%) and a minority was international organizations (11%). This distribution varies in both countries – in Brazil, most documents were connected to universities while in Portugal the great majority were promoted by national organs (Table 1).

Documents in Brazil focus mainly on social inequalities in health in broad terms (59%), while most (71%) in Portugal refer to inequalities in social conditions. The groups of documents selected, related to professionals, to the type of inequality, the classification of the document and the type of training approach used, are shown in Chart 1.

1. Dimension of scientific production about social inequalities in health and HRH training

In view of the fact that the first National Health Plan (PNS) was implemented in Portugal in 2004, and that in 2006 Brazil created the Program of Qualification & Structuring for Health work Management and Education - PROGESUS, for the Unified Health System (SUS), we established two periods of analysis: 2000-2005 and 2006-2012.

We ascertained that out of thirty-nine documents found in the two countries, those that were relevant and published between 2000 and 2005 have a strong situation diagnosis component; are based only on a review of literature and documental analysis³⁰30. Cruz KT. A formação Médica no Discurso da CINAEM-Comissão Interinstitucional Nacional de Avaliação do Ensino Médico [dissertação]. Campinas: Universidade Estadual de Campinas; 2004.–³⁴34. Negri B. A Política de Saúde no Brasil nos anos 90: avanços e limites. Brasília: Ministério da Saúde; 2002. (Série B. Textos Básicos de Saúde).two of which³⁵35. Deluiz N. Qualificação, competências e certificação: visão do mundo do trabalho. Brasília: OPAS, OMS; 2001. Relatório online. [acessado 2013 jan 1]. Disponível em: http://www.paho.org/bra/index.php?option=com_docman&task=doc_details&gid=585&Itemid=
http://www.paho.org/bra/index.php?option... ,³⁶36. Fonseca CD, Seixas PHD, Campos FE, Santana JP, organizadores. Política de recursos humanos em saúde - Seminário Internacional.Brasil: Ministério da Saúde; 2002. do not describe the methodology used. Only one study assessed the setting up of the Human Resources Information & Management System in Health SIG-RHS³⁷37. Pierantoni CR. Reformas da saúde e recursos humanos: novos desafios x velhos problemas [dissertação]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2000..

In the case of documents related to the period between 2006 and 2012, these also showed a predominance of theoretical studies or literature reviews³⁸38. Gijón-Sánchez MT, Pinzón-Pulido S, Kolehmainen-Aitken RL, Weekers J, Acuña DL, Benedict R, Peiro MJ. Better health for all in Europe: Developing a migrant sensitive health workforce. Eurohealth 2010; 16(1):17-19.–⁵⁶56. Vieira ALS, Amâncio Filho A, organizadores. Dinâmica das graduações em saúde no Brasil: subsídios para uma política de recursos humanos. Brasília: Ministério da Saúde, Fundação Oswaldo Cruz; 2006., (one of which did not define the methodology used⁵⁷57. Pires-Alves F, Paiva CHA, Hochman G. História, saúde e seus trabalhadores: da agenda internacional às políticas brasileiras. Cien Saude Colet 2008; 13(3):819-829.). The tendency to conduct a situation diagnosis is maintained in the empirical studies for the first period⁵⁸58. Portugal. Ministério da Saúde. Saúde e Violência Contra as Mulheres. Lisboa: Direcção Geral da Saúde; 2005.,⁵⁹59. Lampert JB. Tendências de Mudanças na Formação Médica no Brasil [dissertação]. Rio de Janeiro: Fundação Oswaldo Cruz; 2002.; and, documents related to the following years⁶⁰60. Aguirre MBF. Avaliação da Implantação da Política Nacional de Ciência, Tecnologia e Inovação em Saúde no Município de Cuiabá [dissertação]. Campinas: Universidade Estadual de Campinas; 2008.–⁶⁸68. Martins RJ, Moimaz SAS, Garbin CAS, Garbin AJI, Lima DC. Percepção dos coordenadores de saúde bucal e cirurgiões-dentistas do serviço público sobre o Sistema Único de Saúde (SUS). Saude Soc. 2009; 18(1):75-82. do not show any implementation or assessment in the area of training policy.

Among the documents mentioned above, the most frequent focused on what is known as "inequality in comprehensive health." In most cases, the authors do not present a definition of the concept of inequality and when this does appear, the authors use the concept outlined by the WHO⁴⁰40. International Organization for Migration (IOM), Gijón-Sánchez MT. Developing a Public Health Workforce for Addressing Migrant Health Needs in Europe. Geneva: IOM; 2006.,⁴³43. Fernandes A, Pereira M, editores. Health and Migration in the European Union: Better Health for All in an Inclusive Society. Lisboa: Instituto Nacional de Saúde Doutor Ricardo Jorge; 2009.,⁴⁶46. Borde E, Akerman M, Pellegrini Filho A. Capacities for research on health and its social determinants: Social Determinants of Health and health inequities in knowledge production and the Brazilian national research system (2005 – 2012). Rio de Janeiro: Fiocruz; 2012. (National mapping report)., or a specific reference⁴⁴44. Rechel B, Mladovsky P, Devillé W, Rijks B, Petrova-Benedict R, Mckee M. Migration and health in the european union. Copenhagen: World Health Organization, European Observatory on health systems and policies; 2011., or do not even indicate a reference for the respective definition³⁸38. Gijón-Sánchez MT, Pinzón-Pulido S, Kolehmainen-Aitken RL, Weekers J, Acuña DL, Benedict R, Peiro MJ. Better health for all in Europe: Developing a migrant sensitive health workforce. Eurohealth 2010; 16(1):17-19.,⁴²42. Portugal R, Padilla B, Ingleby D, Freitas C, Lebas J, Miguel JP. Good Practices on Health and Migration in the EU. Final Draft: Conference Health and Migration in the EU: Better health for all in an inclusive society. Lisbon; 2007.. The way that health professionals are studied varies greatly, but most do this in general terms³³33. Rigoli F, Dussault G. The interface between health sector reform and human resources in health. Human Resources for Health 2003; 1:9.,³⁵35. Deluiz N. Qualificação, competências e certificação: visão do mundo do trabalho. Brasília: OPAS, OMS; 2001. Relatório online. [acessado 2013 jan 1]. Disponível em: http://www.paho.org/bra/index.php?option=com_docman&task=doc_details&gid=585&Itemid=
http://www.paho.org/bra/index.php?option... ,³⁸38. Gijón-Sánchez MT, Pinzón-Pulido S, Kolehmainen-Aitken RL, Weekers J, Acuña DL, Benedict R, Peiro MJ. Better health for all in Europe: Developing a migrant sensitive health workforce. Eurohealth 2010; 16(1):17-19.,⁴⁰40. International Organization for Migration (IOM), Gijón-Sánchez MT. Developing a Public Health Workforce for Addressing Migrant Health Needs in Europe. Geneva: IOM; 2006.–⁴⁴44. Rechel B, Mladovsky P, Devillé W, Rijks B, Petrova-Benedict R, Mckee M. Migration and health in the european union. Copenhagen: World Health Organization, European Observatory on health systems and policies; 2011.,⁴⁶46. Borde E, Akerman M, Pellegrini Filho A. Capacities for research on health and its social determinants: Social Determinants of Health and health inequities in knowledge production and the Brazilian national research system (2005 – 2012). Rio de Janeiro: Fiocruz; 2012. (National mapping report).,⁵⁰50. Garcia ACP. Gestão do trabalho e da educação na saúde: uma reconstrução histórica e política [dissertação]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2010.,⁵¹51. Ferreira MAL, Moura AAG. Evolução da política de recursos humanos a partir da análise das conferências nacionais de saúde (CNS)[monografia]. Rio de Janeiro: Fiocruz; 2006.,⁵⁸58. Portugal. Ministério da Saúde. Saúde e Violência Contra as Mulheres. Lisboa: Direcção Geral da Saúde; 2005.,⁶⁰60. Aguirre MBF. Avaliação da Implantação da Política Nacional de Ciência, Tecnologia e Inovação em Saúde no Município de Cuiabá [dissertação]. Campinas: Universidade Estadual de Campinas; 2008.,⁶²62. Miyagima CH. Produção do conhecimento e serviço na saúde: (des) conexões entre teoria e prática [dissertação]. São Paulo: PUCSP; 2009.,⁶⁵65. Santos R. Formação e Desenvolvimento de Recursos Humanos em Saúde: Análise dos Projetos de Educação Permanente [dissertação]. Florianópolis: Universidade Federal de Santa Catarina; 2007., while others deal with all professionals included in this review³⁷37. Pierantoni CR. Reformas da saúde e recursos humanos: novos desafios x velhos problemas [dissertação]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2000.,³⁹39. Ceccim RB, Pinto LF. A formação e especialização de profissionais de saúde e a necessidade política de enfrentar as desigualdades sociais e regionais. Rev. bras. educ. Méd 2007; 31(3):266-277.,⁴⁷47. Canesqui AM. Temas e abordagens das ciências sociais e humanas em saúde na produção acadêmica de 1997 a 2007. Cien Saude Colet 2010; 15(4):1955-1966.,⁴⁹49. Conceição C, Ribeiro JS, Pereira J, Dussault G. Portugal Mobility of Health Professionals. Relatório online; 2001. [acessado 2013 jan 1]. Disponível em: http://www.portaldasaude.pt/portal
http://www.portaldasaude.pt/portal... ,⁵²52. Almeida DCS. A Formação Superior e as Conferências Nacionais de Recursos Humanos em Saúde [dissertação]. Londrina: Universidade Estadual de Londrina; 2008.,⁵⁵55. Haddad AE, Morita MC, Pierantoni CR, Brenelli SL, Passarella T, Campos FE. Formação de profissionais de saúde no Brasil: uma análise no período de 1991 a 2008. Rev Saude Publica 2010; 44(3):383-393.–⁵⁷57. Pires-Alves F, Paiva CHA, Hochman G. História, saúde e seus trabalhadores: da agenda internacional às políticas brasileiras. Cien Saude Colet 2008; 13(3):819-829.,⁶¹61. Armani TB. Formação de Sanitaristas: cartografias de uma pedagogia na Educação em Saúde Coletiva [dissertação]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2006.,⁶³63. Marin MJS, Gomes R, Marvulo MML, Primo EM, Barbosa PMK, Druzian S. Pós-graduação multiprofissional em saúde: resultados de experiências utilizando metodologias ativas. Interface (Botucatu) 2010; 14(33):331-344.. We found eleven documents where the professional categories had been studied separately (physicians, nurses and dentists)³⁰30. Cruz KT. A formação Médica no Discurso da CINAEM-Comissão Interinstitucional Nacional de Avaliação do Ensino Médico [dissertação]. Campinas: Universidade Estadual de Campinas; 2004.,³¹31. Santana JP, Christófaro MAC. Introdução à Reforma Educacional Brasileira. s.l; s.n: 2001 (OPS. Publicación Cientifica e Técnica). [acessado 2013 jan 1]. Disponível em: http://www.opas.org.br
http://www.opas.org.br... ,⁴⁵45. Modesto AA. A interdisciplinaridade e a integralidade na formação em Odontologia no contexto do SUS: um estudo sobre as contribuições teórico-conceituais acerca dos cenários de práticas de ensino em odontologia[dissertação]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2010.,⁴⁶46. Borde E, Akerman M, Pellegrini Filho A. Capacities for research on health and its social determinants: Social Determinants of Health and health inequities in knowledge production and the Brazilian national research system (2005 – 2012). Rio de Janeiro: Fiocruz; 2012. (National mapping report).,⁵³53. Feuerwerker LCM. A formação de médicos especialistas e a residência médica no Brasil. Saúde em Debate 2001; 25(57):39-54.,⁵⁴54. Petta HL. Formação de médicos especialistas no SUS: descrição e análise da implementação do Programa Nacional de Apoio à Formação de Médicos Especialistas em Áreas Estratégicas (Pro-Residência) [dissertação]. Rio de Janeiro: Fundação Oswaldo Cruz; 2011.,⁵⁹59. Lampert JB. Tendências de Mudanças na Formação Médica no Brasil [dissertação]. Rio de Janeiro: Fundação Oswaldo Cruz; 2002.,⁶⁴64. Dias HS. A implementação da política de reorientação da formação em odontologia: dependência de trajetória e estímulos institucionais na UFBA[dissertação]. Rio de Janeiro: Fiocruz; 2011.,⁶⁶66. World Health Organization (WHO). Nurses and Midwives: A force for health Survey on the situation of nursing and midwifery in the Member States of the European Region of the World Health Organization 2009. Copenhague: WHO Regional Office for Europe; 2010.–⁶⁸68. Martins RJ, Moimaz SAS, Garbin CAS, Garbin AJI, Lima DC. Percepção dos coordenadores de saúde bucal e cirurgiões-dentistas do serviço público sobre o Sistema Único de Saúde (SUS). Saude Soc. 2009; 18(1):75-82. and a further three documents that approached problems involving physicians and nurses³²32. Baganha MI, Ribeiro JS, Pires S. O sector da Saúde em Portugal: funcionamento do sistema e caracterização sócio-profissional. Relatório online; 2002. [acessado 2013 jan 1]. Disponível em: http://www.portaldasaude.pt/ portal
http://www.portaldasaude.pt/portal... ,³⁴34. Negri B. A Política de Saúde no Brasil nos anos 90: avanços e limites. Brasília: Ministério da Saúde; 2002. (Série B. Textos Básicos de Saúde).,³⁶36. Fonseca CD, Seixas PHD, Campos FE, Santana JP, organizadores. Política de recursos humanos em saúde - Seminário Internacional.Brasil: Ministério da Saúde; 2002..

There is a predominance of type A documents – those which only mention or address the problem of social inequality in health (ten); and B – documents that mention or present and discuss the problem (sixteen). Fewer documents relate to type C – documents that present solutions or strategies or interventions in terms of training (eight); and in D – documents that assess HRH training policies (five). With these findings, we could see that very little information has been produced on the subject, which contains an evaluative dimension on HRH training policies in general, as well as those related to the professionals being investigated.

2. Scientific production on the articulation between HRH training and social inequalities in health

Aspects related, either directly or indirectly, to HRH training are the main focus of thirty of the thirty-seven documents. The remaining documents focus on social inequalities in health and at the same time address several questions related to training.

When we analyzed the way inequality is treated in the thirty documents whose main focus is related to the training of health professionals, we identified the following five levels: residual inequality, with only one mention of the word "inequality" and unrelated to the present subject matter of training issues³¹31. Santana JP, Christófaro MAC. Introdução à Reforma Educacional Brasileira. s.l; s.n: 2001 (OPS. Publicación Cientifica e Técnica). [acessado 2013 jan 1]. Disponível em: http://www.opas.org.br
http://www.opas.org.br... ,³⁵35. Deluiz N. Qualificação, competências e certificação: visão do mundo do trabalho. Brasília: OPAS, OMS; 2001. Relatório online. [acessado 2013 jan 1]. Disponível em: http://www.paho.org/bra/index.php?option=com_docman&task=doc_details&gid=585&Itemid=
http://www.paho.org/bra/index.php?option... ,⁴⁷47. Canesqui AM. Temas e abordagens das ciências sociais e humanas em saúde na produção acadêmica de 1997 a 2007. Cien Saude Colet 2010; 15(4):1955-1966.,⁶⁷67. Zilbovicius C. Implantação das diretrizes curriculares para cursos de graduação em odontologia no Brasil: contradições e perspectivas[dissertação]. São Paulo: Universidade de São Paulo; 2007.; indirect inequality, in that the discussion about training of health professionals only indirectly involves inequality, without discussing its relationship with HRH training policies and interventions, or with SUS equity objectives SUS³⁴34. Negri B. A Política de Saúde no Brasil nos anos 90: avanços e limites. Brasília: Ministério da Saúde; 2002. (Série B. Textos Básicos de Saúde).,³⁶36. Fonseca CD, Seixas PHD, Campos FE, Santana JP, organizadores. Política de recursos humanos em saúde - Seminário Internacional.Brasil: Ministério da Saúde; 2002.,⁴⁵45. Modesto AA. A interdisciplinaridade e a integralidade na formação em Odontologia no contexto do SUS: um estudo sobre as contribuições teórico-conceituais acerca dos cenários de práticas de ensino em odontologia[dissertação]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2010.,⁴⁸48. Casotti E. Odontologia no Brasil: uma (breve) história do pensamento sobre o ensino [dissertação]. Rio de Janeiro: Universidade Federal do Rio de Janeiro; 2009.,⁵¹51. Ferreira MAL, Moura AAG. Evolução da política de recursos humanos a partir da análise das conferências nacionais de saúde (CNS)[monografia]. Rio de Janeiro: Fiocruz; 2006.,⁵⁷57. Pires-Alves F, Paiva CHA, Hochman G. História, saúde e seus trabalhadores: da agenda internacional às políticas brasileiras. Cien Saude Colet 2008; 13(3):819-829.,⁶¹61. Armani TB. Formação de Sanitaristas: cartografias de uma pedagogia na Educação em Saúde Coletiva [dissertação]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2006.,⁶³63. Marin MJS, Gomes R, Marvulo MML, Primo EM, Barbosa PMK, Druzian S. Pós-graduação multiprofissional em saúde: resultados de experiências utilizando metodologias ativas. Interface (Botucatu) 2010; 14(33):331-344.–⁶⁵65. Santos R. Formação e Desenvolvimento de Recursos Humanos em Saúde: Análise dos Projetos de Educação Permanente [dissertação]. Florianópolis: Universidade Federal de Santa Catarina; 2007.,⁶⁸68. Martins RJ, Moimaz SAS, Garbin CAS, Garbin AJI, Lima DC. Percepção dos coordenadores de saúde bucal e cirurgiões-dentistas do serviço público sobre o Sistema Único de Saúde (SUS). Saude Soc. 2009; 18(1):75-82. and the contribution this has made towards tackling regional inequalities, or as part of understanding the context³⁰30. Cruz KT. A formação Médica no Discurso da CINAEM-Comissão Interinstitucional Nacional de Avaliação do Ensino Médico [dissertação]. Campinas: Universidade Estadual de Campinas; 2004.,³⁹39. Ceccim RB, Pinto LF. A formação e especialização de profissionais de saúde e a necessidade política de enfrentar as desigualdades sociais e regionais. Rev. bras. educ. Méd 2007; 31(3):266-277.,⁴⁹49. Conceição C, Ribeiro JS, Pereira J, Dussault G. Portugal Mobility of Health Professionals. Relatório online; 2001. [acessado 2013 jan 1]. Disponível em: http://www.portaldasaude.pt/portal
http://www.portaldasaude.pt/portal... ,⁵⁹59. Lampert JB. Tendências de Mudanças na Formação Médica no Brasil [dissertação]. Rio de Janeiro: Fundação Oswaldo Cruz; 2002., or even to register HRH training within the scope of the National Policy for Science, Technology & Innovation in Health – PNCTIS, which is also designed as "an instrument to reduce health inequality"; latent inequality (without integration in interventions) because inequalities are recognized as one of the greatest challenges in nursing, but which do not present any relationship with the question of training and its role, for example, in reinforcing the competencies of these professionals in dealing with vulnerable populations⁶⁶66. World Health Organization (WHO). Nurses and Midwives: A force for health Survey on the situation of nursing and midwifery in the Member States of the European Region of the World Health Organization 2009. Copenhague: WHO Regional Office for Europe; 2010.; adjustment to inequality involving the challenges shown, either in terms of HRH training related to existing national and regional inequalities⁵⁰50. Garcia ACP. Gestão do trabalho e da educação na saúde: uma reconstrução histórica e política [dissertação]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2010., national social inequalities³²32. Baganha MI, Ribeiro JS, Pires S. O sector da Saúde em Portugal: funcionamento do sistema e caracterização sócio-profissional. Relatório online; 2002. [acessado 2013 jan 1]. Disponível em: http://www.portaldasaude.pt/ portal
http://www.portaldasaude.pt/portal... , or problems of training specialist physicians and inequalities in regional distribution⁵³53. Feuerwerker LCM. A formação de médicos especialistas e a residência médica no Brasil. Saúde em Debate 2001; 25(57):39-54.,⁵⁴54. Petta HL. Formação de médicos especialistas no SUS: descrição e análise da implementação do Programa Nacional de Apoio à Formação de Médicos Especialistas em Áreas Estratégicas (Pro-Residência) [dissertação]. Rio de Janeiro: Fundação Oswaldo Cruz; 2011., or in terms of HRH policies related to inequalities in the country³⁷37. Pierantoni CR. Reformas da saúde e recursos humanos: novos desafios x velhos problemas [dissertação]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2000., or even the evolution of courses adapted to the National HRH Conferences and articulated with social movements in Brazil⁵²52. Almeida DCS. A Formação Superior e as Conferências Nacionais de Recursos Humanos em Saúde [dissertação]. Londrina: Universidade Estadual de Londrina; 2008.; strategic inequality appears in documents where training is presented as a strategy to achieve equity³³33. Rigoli F, Dussault G. The interface between health sector reform and human resources in health. Human Resources for Health 2003; 1:9. or to reduce inequalities³⁸38. Gijón-Sánchez MT, Pinzón-Pulido S, Kolehmainen-Aitken RL, Weekers J, Acuña DL, Benedict R, Peiro MJ. Better health for all in Europe: Developing a migrant sensitive health workforce. Eurohealth 2010; 16(1):17-19.; or even as a strategy to reduce inequalities in HRH, by distributing courses⁵⁵55. Haddad AE, Morita MC, Pierantoni CR, Brenelli SL, Passarella T, Campos FE. Formação de profissionais de saúde no Brasil: uma análise no período de 1991 a 2008. Rev Saude Publica 2010; 44(3):383-393.,⁵⁶56. Vieira ALS, Amâncio Filho A, organizadores. Dinâmica das graduações em saúde no Brasil: subsídios para uma política de recursos humanos. Brasília: Ministério da Saúde, Fundação Oswaldo Cruz; 2006..

The seven remaining documents⁴⁰40. International Organization for Migration (IOM), Gijón-Sánchez MT. Developing a Public Health Workforce for Addressing Migrant Health Needs in Europe. Geneva: IOM; 2006.–⁴⁴44. Rechel B, Mladovsky P, Devillé W, Rijks B, Petrova-Benedict R, Mckee M. Migration and health in the european union. Copenhagen: World Health Organization, European Observatory on health systems and policies; 2011.,⁴⁶46. Borde E, Akerman M, Pellegrini Filho A. Capacities for research on health and its social determinants: Social Determinants of Health and health inequities in knowledge production and the Brazilian national research system (2005 – 2012). Rio de Janeiro: Fiocruz; 2012. (National mapping report).,⁵⁸58. Portugal. Ministério da Saúde. Saúde e Violência Contra as Mulheres. Lisboa: Direcção Geral da Saúde; 2005. focus mainly on inequalities among migrant populations, and are heterogenic in the way they deal with questions of training. This makes us believe there is an indirect relationship between problems of inequality and the training of "health technicians," when emphasis is given to the importance of alerting them to these issues and that they could become "agents in the reduction of inequalities."

3. Policies and interventions in HRH training and social inequality in health

The fourteen documents selected which are related to Policies include legal documents, Ministry of Health interventions, the National Health Plans and reports supporting policies. These documents refer only to unequal social conditions (six) and widespread inequalities (eight) and none of these define inequality according to the concept used. Fewer texts were found for the first period (2000-2005), which only consist of legal documents, in which National Health Plans, both in Portugal⁶⁹69. Portugal. Ministério da Saúde. Plano Nacional de Saúde 2004-2010. Lisboa: Direcção Geral da Saúde; 2004. and in Brazil⁷⁰70. Brasil. Ministério da Saúde. Plano Nacional de Saúde/ PNS - Um Pacto pela Saúde no Brasil. Diário Oficial da União 2004; 13 dez., deal with physicians, nurses and dentists, which shows a more specific approach as regards the other Plans, where health professionals are examined in more general terms⁷¹71. Portugal. Presidência do Conselho de Ministros. II Plano Nacional para a Igualdade 2003-2006. Diário da República 2003; 25 nov.–⁷³73. Brasil. Ministério da Saúde (MS). Política Nacional de Educação Permanente dos Trabalhadores do Ministério da Saúde (PNEP-MS). Brasil: MS; 2004.. With respect to inequalities, these are dealt with mainly based on the typology of their unequal social conditions.

During the second period (2006-2012), we found a greater number (nine) and variety in the type of document available, since in addition to legal documents⁷⁴74. Portugal. Presidência do Conselho de Ministros. IV Plano Nacional Contra a Violência Doméstica (2011-2013). Diário da República 2010; 17 dez.–⁷⁶76. Portugal. Ministério da Saúde, Direcção Geral da Saúde. Plano Nacional de Saúde 2012-2016; Lisboa: Direcção Geral da Saúde 2012. [acessado 2013 jan 1]. Disponível em: http://www.dgs.pt
http://www.dgs.pt... there are also the Ministry of Health interventions⁷⁷77. Portugal. Ministro da Saúde. A intervenção da saúde na prevenção, deteção e resposta à violência doméstica. Lisboa: Ministério da Saúde; 2012. [acessado 2013 jan]. Acessível em: http://www.portaldasaude.pt/portal
http://www.portaldasaude.pt/portal... ,⁷⁸78. Portugal. Ministro da Saúde. Intervenção do Ministro do Ministro da Saúde na Cerimônia comemorativa do Dia Mundial da Saúde. Lisboa: Ministério da Saúde; 2007. [acessado 2013 jan 1]. Disponível em: http://www.portaldasaude.pt/portal
http://www.portaldasaude.pt/portal... , as well as technical reports supporting this policy⁷⁹79. Brasil. Ministério da Saúde (MS). Conselho Nacional de Saúde. Política nacional de educação permanente para o controle social no Sistema Único de Saúde – SUS. Brasília: Editora do Ministério da Saúde; 2006. (Série B. Textos Básicos em Saúde).–⁸²82. Brasil. Ministério da Saúde (MS). Conselho Nacional de Saúde. Relatório Final da 14ª Conferência Nacional de Saúde: Todos Usam o SUS. SUS na Seguridade Social-– Política Pública, Patrimônio do Povo Brasileiro. Brasília: Editora do Ministério da Saúde; 2012. (Série C. Projetos, Programas e Relatórios).. With respect to the latter, related to Brazil, three mentioned physicians, nurses and dentists and one dealt specifically with physicians and nurses, where inequality was presented in broader terms. This trend persists, in that the only legal documents from Brazil⁷⁵75. Brasil. Ministério da Saúde (MS). Política Nacional de Promoção da Saúde. Brasília: MS; 2006. (Série B. Textos Básicos de Saúde). mention the same type of inequality.

The documents related to Portugal⁷⁴74. Portugal. Presidência do Conselho de Ministros. IV Plano Nacional Contra a Violência Doméstica (2011-2013). Diário da República 2010; 17 dez.,⁷⁷77. Portugal. Ministro da Saúde. A intervenção da saúde na prevenção, deteção e resposta à violência doméstica. Lisboa: Ministério da Saúde; 2012. [acessado 2013 jan]. Acessível em: http://www.portaldasaude.pt/portal
http://www.portaldasaude.pt/portal... ,⁷⁸78. Portugal. Ministro da Saúde. Intervenção do Ministro do Ministro da Saúde na Cerimônia comemorativa do Dia Mundial da Saúde. Lisboa: Ministério da Saúde; 2007. [acessado 2013 jan 1]. Disponível em: http://www.portaldasaude.pt/portal
http://www.portaldasaude.pt/portal... deal with these professionals in a general way, with the exception of the PNS⁷⁶76. Portugal. Ministério da Saúde, Direcção Geral da Saúde. Plano Nacional de Saúde 2012-2016; Lisboa: Direcção Geral da Saúde 2012. [acessado 2013 jan 1]. Disponível em: http://www.dgs.pt
http://www.dgs.pt... , where health professionals are treated according to their professional category.

Discussion

The findings of this survey indicate a predominance of theoretical studies and review of the literature conclude that scientific evidence can only contribute towards the introduction of and support to issues included in the political agenda.

Research findings can contribute with at least three of the stages involved in preparing policies: defining the agenda, establishing policies and implementation¹⁴14. Hanney SR, Gonzalez-Block MA, Buxton MJ, Kogan M. The utilization of health research in policy-making: concepts, examples and methods of assessment. Health Research Policy and System 2003; 1:2. [acessado 2012 fev 1]. Disponível em: http://www.health-policy-systems.com/content/1/1/2
http://www.health-policy-systems.com/con... . This process includes preparing recommendations made by decision-makers, which requires evidence about the effectiveness of the interventions, as well as many other forms of evidence⁹9. World Health Organization (WHO). Everybody business: strengthening health systems to improve health outcomes. Geneva: WHO framework for action; 2007.. An essential component of this process involves assessing the types of available evidence about health system interventions⁸³83. Lewin S, Bosch-Capblanch X, Oliver S, Akl EA, Vist GE, Lavis JN, Ghersi D, Røttingen JA, Steinmann P, Gulmezoglu M, Tugwell P, El-Jardali F, Haines A. Guidance for Evidence-Informed Policies about Health Systems: Assessing How Much Confidence to Place in the Research Evidence. PLoS Med 2012; 9(3):e1001187. [acessado 2012 set]. Disponível em: http://dx.doi. org/10.1371/journal.pmed.1001187
http://dx.doi.org/10.1371/journal.pmed.1... .

Thus, through this study, we conclude that very little knowledge is produced that involves components to assess HRH training policies in general and considered as those related to the professionals being examined, with no scientific support available to enable policies to be based on evidence.

Identifying factors seen as essential to formulate policies for evidence-based social inequalities in health⁸⁴84. Choi BCK. Understanding the basic principles of knowledge translation. J Epidemiol Community Health 2005; 59(2):93.,⁸⁵85. World Health Organization (WHO). World Report on Knowledge for Better Health - Strengthening Health Systems. Geneva: WHO; 2004. can occur in two ways: 1) politicians make use of scientific data on social inequalities in health so as to maintain this issue within the public agenda, since without data such problems remain invisible. Even so, scientific evidence should be presented in non-technical language; 2) policy-makers, scientists; health professionals, non-governmental organizations and the public join forces to introduce social inequalities in health into the public agenda. In this case, the scientific community can provide relevant evidence to enable equity strategies to be adopted, leaving it up to the policy-makers and health professionals to guarantee that these strategies are implemented⁸⁶86. Whitehead M. Diffusion of ideas on social inequalities in health: a European perspective. Milbank Q 1998; 76(3):469-492.,⁸⁷87. Machenbach JP, Bakker MJ. Tackling socioeconomic inequalities in health: analysis of European experiences. Lancet 2003; 362(9393):1409-1414..

In both cases, the research findings should be presented to their target-groups in non-technical language. Likewise, in order to strengthen the findings of the research, it would be necessary to concentrate on the capacities of both the decision-makers and their teams to evaluate the applicability, and relevance of the results and quality of those studies⁸⁸88. El-Jardali F, Ataya N, Jamal D, Jaafar M. A multi-faceted approach to promote knowledge translation platforms in eastern Mediterranean countries: climate for evidence-informed policy. Health Res Policy Syst 2012; 10:15.,⁸⁹89. Oxman AD, Vandvik PO, Lavis JN, Fretheim A, Lewin S. SUPPORT Tools for evidence-informed health Policy-making (STP) 2: Improving how your organisation supports the use of research evidence to inform policymaking. Health Research Policy and Systems 2009; 7(Supl. 1):S2..

In order to use research findings to formulate and implement policies, it would be necessary to conduct studies to identify and evaluate how interventions have reduced social inequality through professional training. This review understands that the scarcity of research reflects the lack of policies that recognize professional training as a strategy to reduce inequalities. Furthermore, we noted that, in spite of an increase in scientific production during the period examined, many lacunae still exist, and that the knowledge production process and its relationship with decision-making could still become separate procedures, in both countries. This is precisely a question we will aim to answer in the second stage of this work.

In Brazil, few studies exist that seek to understand, even indirectly, how HRH training helps to reduce social inequalities in health. This is an issue raised by Bosi and Paim⁹⁰90. Bosi MLM, Paim JS. Graduação em Saúde Coletiva: limites e possibilidades como estratégia de formação profissional. Cien Saude Colet 2010; 15(4):2029-2038., who discuss the main characteristics of professional training in the public health sector at undergraduate level; and Dias et al.⁹¹91. Dias HS, Lima LD, Teixeira M. A trajetória da política nacional de reorientação da formação profissional em saúde no SUS. Cien Saude Colet2013; 18(6):1613-1624., who analyzed the history of a national policy for the reorientation of professional health training for the Unified Health System (SUS).

Over the last few years, new mechanisms have been established in Brazil that are designed to reduce inequalities not always related to scientific production, especially those found in the distribution of primary healthcare professionals, i.e., the Family Health Strategy. The study by Borde et al.⁴⁶46. Borde E, Akerman M, Pellegrini Filho A. Capacities for research on health and its social determinants: Social Determinants of Health and health inequities in knowledge production and the Brazilian national research system (2005 – 2012). Rio de Janeiro: Fiocruz; 2012. (National mapping report). showed that until the 1990s, in spite of the predominance of theoretical or conceptual research about health determinants, this helped place Brazilian research at the center of the political and academic agenda in Latin America. Even so, the scope and impact of social determinants in health and research into inequalities in health continue to be restricted to the academic community, with strong, though still insufficient implications in the formulation of policies and in health indicators⁴⁶46. Borde E, Akerman M, Pellegrini Filho A. Capacities for research on health and its social determinants: Social Determinants of Health and health inequities in knowledge production and the Brazilian national research system (2005 – 2012). Rio de Janeiro: Fiocruz; 2012. (National mapping report)..

From the point of view of health training, more recent studies about undergraduate courses in public health⁹²92. Belisário SA, Pinto ICM, Castellanos MEP, Nunes TCM, Fagundes TLQ, Gil CR, Aguiar RAT, Viana SV, Corrêa GT. Implantação do curso de graduação em saúde coletiva: a visão dos coordenadores. Cien Saude Colet 2013; 18(6):1625-34.,⁹³93. Teixeira CFS, Coelho MTAD, Rocha MND. Bacharelado interdisciplinar: uma proposta inovadora na educação superior em saúde no Brasil. Cien Saude Colet 2013; 18(6):1635-1646. discuss the process of its creation and implementation, seeing this as an irreversible reality in the field of interdisciplinary health training in Brazil, though pressured by traditional models of disciplinary training.

No studies were found in Portugal that establish a direct relationship between HRH and how this could eventually help reduce the social inequalities that still exist in health⁹⁴94. Observatório Português dos Sistemas de Saúde. Relatório de Primavera 2013. Duas faces da saúde. Lisboa: Observatório Português dos Sistemas de Saúde; 2013.. However, the organs that financed these investigations did not define this issue as a priority.

In the case of Europe, in 2013 the WHO⁹⁵95. World Health Organization (WHO). The European health report 2012: charting the way to well-being. Copenhagen: World Health Organization Regional Office for Europe; 2013. presented six overall objectives for Health 2020: reduce premature mortality rates by 2020, increase life expectancy, reduce health inequalities, improve the well-being of the European population, provide universal health coverage and establish national goals for all member states. In other words, the fight against social inequalities in health will continue to be one of the priorities within the area of the European Union (EU), including Portugal, although this objective is not related to more specific lines of action, including what role should be played by HRH and their training.

All countries need consolidated systems to examine ways to help improve the health and well-being of their populations⁹⁶96. Alger J, Becerra-Posada F, KennedyA, Martinelli E, Cuervo LG. Grupo Colaborativo de la primera conferencia latino-americana de investigación e innovación para la salud. Sistemas nacionales de investigación para la salud en América Latina: una revisión de 14 países. Rev Panam Salud Publica 2009; 26(5):447-457.. However, in Portugal there is still no health investigation system that guarantees a balanced scientific understanding of the national reality⁶⁹69. Portugal. Ministério da Saúde. Plano Nacional de Saúde 2004-2010. Lisboa: Direcção Geral da Saúde; 2004. (National Health Plan 2004-2010, 69, p.79). It was only in 2006 that the "National Agenda of Health Research Priorities" was implemented in Brazil, the most important action of which was to legitimize the National Policy for Science, Technology & Innovation in Health (PNCTIS) in the country, in line with the principles of the SUS. This profile differs from that which occurs in other countries where there is already a well-established culture for funding agencies to provide support to incorporate evidence-based findings into political decisions⁹⁷97. Smits PA, Denis JL. How research funding agencies support science integration into policy and practice: an international overview. Implement Sci 2014; 9:28..

In recent years in Brazil, whenever a priority research agenda is being defined, part of this involves integrating the different actors into the process of knowledge production. Thus, in both the case of Brazil and Portugal, the findings of this study confirm the fragility of the relationship that exists between science and other areas of society, namely the health sector¹⁶16. Pellegrini Filho A. Pesquisa em saúde, política de saúde e equidade na América Latina. Cien Saude Colet 2004; 9(2):339-350..

This study also shows that there is a low level of integration between knowledge produced that is focused on training health professionals and social inequalities in health. That is, analytical studies tend to treat social inequality in health in a residual, indirect and latent manner, which can mean that full use is not made of evidence of social inequalities and, as a result, that this issue is not included in the policy agenda. The fact that funding agencies in Brazil give low priority to research that involves training, might well explain why there is a predominance of studies about HRH management that are unrelated to training.

We noted that, in the last two years, this trend has started to change, when the main funding agencies include studies about training in their research agendas. Even so, such agendas are still isolated and fragmented.

The current research agenda of the Department of Science & Technology (DECIT) includes the following components: training, with greater emphasis on user satisfaction; ongoing education; labor market analysis; calculating the size of the health labor force; regulations; workers and management of national training programs such as the Brazil Network of the National Telehealth Program (Telessaúde), namely the Program to Support the Training of Medical Specialists in Strategic Areas (Pró-Residência), the National Program for the Reorientation of Professional Health Training (Pró-Saúde), and the Education Program for Health Work (Pet-Saude); as well as research into medical demographics, migration, retaining and keeping resident physicians in the country⁹⁸98. Chamada MCTI/CNPq/MS - SCTIE - Decit Nº 08/2013 -Pesquisa em educação permanente para o SUS e dimensionamento da força de trabalho em saúde[internet] Conselho Nacional de Pesquisa; 2013. [acessado 2013 set 1]. Disponível em: http://www. cnpq.br/web/guest/chamadas-publicas?p_p_id=resultadosportlet_WAR_resultadoscnpqportlet_INSTANCE_0ZaM&filtro=abertas&detalha=chamadaDivulgada&idDivulgacao=3202
http://www.cnpq.br/web/guest/chamadas-pu... .

These initiatives can help ensure that their program priorities reflect the research work that has been developed in this area.

Final considerations

In summary, as regards Portugal, the relationship between inequalities in health and the training of health professionals mainly involves issues related to immigrants, which may reflect the more general concerns shown by the EU in this matter⁴⁹49. Conceição C, Ribeiro JS, Pereira J, Dussault G. Portugal Mobility of Health Professionals. Relatório online; 2001. [acessado 2013 jan 1]. Disponível em: http://www.portaldasaude.pt/portal
http://www.portaldasaude.pt/portal... .

In Brazil, the relationship between health professionals and social inequalities in health, in particular, the inequality in the distribution of these professionals is expressed through the work of professionals with vulnerable groups³⁹39. Ceccim RB, Pinto LF. A formação e especialização de profissionais de saúde e a necessidade política de enfrentar as desigualdades sociais e regionais. Rev. bras. educ. Méd 2007; 31(3):266-277., the insecurity and segmentation of working relationships between these professionals within the public health system⁹⁹99. Marques APP. Reestruturação produtiva e recomposições do trabalho e emprego: um périplo pelas "novas" formas de desigualdade social. Cien Saude Colet 2013; 18(6):1545-1554. and the fragility of health work market regulations¹⁰⁰100. Martins MIC, Molinaro A. Reestruturação produtiva e seu impacto nas relações de trabalho nos serviços públicos de saúde no Brasil. Cien Saude Colet 2013; 18(6):1667-1676.".

It is important to clarify that this study contains two limitations. The first relates to the nature of the data sources, specifically to the diversity of key word definitions found in the data banks. In line with other authors¹⁰¹101. Crawford MJ, Rutter D, Manley C, Weaver T, Bhui K, Fulop N, Tyrer P. Systematic review of involving patients in the planning and development of health care. BMJ 2002; 325(7375):1263.,¹⁰²102. Dixon-Woods M, Bonas S, Booth A, Jones DR, Miller T, Sutton AJ, Shaw RL, Smith JA, Young B. How can systematic reviews incorporate qualitative research? A critical perspective. Qualitative Research 2006; 6(1): 27-44., we also understand that certain features are inherent to studies which subjects are related to policies, with consequences on studies/documents selected and methodologies used. The second limitation concerns to the possible bias contained in published works¹⁰³103. Sousa MR, Ribeiro ALP. Revisão Sistemática e Meta-análise de Estudos de Diagnóstico e Prognóstico: um Tutorial. Arq Bras Cardiol 2009; 92(3):241-251., since it is possible that, in the case of both countries, that we did not manage to trace all research papers issued or produced by the respective Ministries of Health, in the event that these were not made available on their respective websites.

Acknowledgements:

To MRP, for the critical review of the final version of this article.

References

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