Abstract

Objective:

to analyze the spatial distribution and temporal trend of human resources for the Brazilian National Health System (SUS) and the Supplemental Health sector.

Methods:

an ecological study was conducted in the country’s 27 Federative Units (FUs); SUS Information Technology Department (DATASUS) data were used relating to the doctor, dental surgeon, nurse and nursing technician personnel categories for the period 2005-2016; Prais-Winsten regression was used to assess the time trend.

Results:

there was an rising trend of Supplemental Health Sector human resources in all personnel categories, with an mean annual increase of 0.054 (95%CI: 0.031;0.076); with regard to SUS, there was an increase in dental surgeons and nursing technicians, with annual increases of 0.008 (95%CI: 0.003;0.011), and 0.066 (95%CI 0.022; 0.087), respectively, while in most FU, nurses showed a stationary trend and doctors showed a stationary or falling trend.

Conclusion:

inequalities were found in human resource distribution, reflecting the health system crisis.

Keywords:
Unified Health System; Supplemental Health; Workforce; Geographic Mapping; Ecological Studies; Time Series Studies

Introduction

The restrictive measures imposed on the Brazilian National Health System (SUS), such as Constitutional Amendment No. 95 (CA 95), which has frozen public expenditure for 20 years with effect from 2019,¹1. Mariano CM. Emenda Constitucional 95/2016 e o teto dos gastos públicos: Brasil de volta ao estado de exceção econômico e ao capitalismo do desastre. Rev Investig Const [Internet]. 2017 jan-abr [citado 2020 mar 23];4(1):259-81. Disponível em: Disponível em: https://doi.org/ 10.5380/rinc.v4i1.50289
https://doi.org/ 10.5380/rinc.v4i1.50289... ^,22. Reis AAC, Sóter APM, Furtado LAC, Pereira SSS. Tudo a temer: financiamento, relação público e privado e o futuro do SUS. Saúde Debate [Internet]. 2016 dez [citado 2020 mar 23];40(spe):122-35. Disponível em: Disponível em: https://doi.org/10.1590/0103-11042016s11
https://doi.org/10.1590/0103-11042016s11... bring to light challenging barriers with regard to the sustainability of a universal health system.³3. Rossi P, Dweck E. Impactos do novo regime fiscal na saúde e educação. Cad Saúde Pública [Internet]. 2016 dez [citado 2020 mar 23];32(12):1-5. Disponível em: Disponível em: https://doi.org/10.1590/0102-311x00194316
https://doi.org/10.1590/0102-311x0019431... Also linked to this issue is the 2017 National Policy on Primary Care, which recognizes other care modalities and not just the Family Health Strategy (ESF).⁴4. Morosini MVGC, Fonseca AF, Lima LD. Política Nacional de Atenção Básica 2017: retrocessos e riscos para o Sistema Único de Saúde. Saúde Debate [Internet]. 2018 jan [citado 2020 mar 23];42(116):11-24. Disponível em: Disponível em: https://doi.org/10.1590/0103-1104201811601
https://doi.org/10.1590/0103-11042018116...

Also adding to this are political decisions that are indifferent to the progress made in Brazil since the inception of the SUS as a universal system, in terms of the reduction in health inequalities and promotion of equity. An example of this progress is the National Immunization Program (PNI) and the direct consequences thereof: reduction in cases of measles, elimination of neonatal tetanus and control of other vaccine-preventable diseases.⁵5. Ministério da Saúde (BR). Programa nacional de imunizações: 30 anos [Internet]. Brasília: Ministério da Saúde; 2013 [citado 2018 ago 5]. 208 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/livro_30_anos_pni.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... Another highlight was the creation of the former National STD/AIDS Program, which revolutionized treatment and reduced the speed at which the global epidemic of human immunodeficiency virus (HIV) infection has spread, by adopting a policy of free distribution of antiretroviral medication,⁶6. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Programa Nacional de DST e Aids. Plano estratégico: Programa Nacional de DST e Aids, 2005 [Internet]. Brasilia: Ministério da Saúde; 2005 [citado 2018 ago 5]. 121 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/plano_estrategico.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... in addition to other important achievements.

It is therefore no surprise that the economic crisis and economic austerity measures put forward as a solution to it have a direct impact on Health, such as CA 95, and have led to the return of former challenges to the SUS.⁷7. Rasella D, Basu S, Hone T, Paes-Sousa R, Ocke-Reis CO, Millett C. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: A nationwide microsimulation study. PLoS Med [Internet]. 2018 May [cited 2020 Mar 23];15(5):e1002570. Available from: https://doi.org/10.1371/journal.pmed.1002570 On the other hand, great faith has been placed in universal health systems as the most efficient strategy for reducing health-related ills, injustices and iniquities, especially in an increasingly globalized world. In countries that adopt health as a universal right, there is heavy investment in human resources for this area - personnel trained in health care - and in policies providing incentives and valuing these workers, promoting improved salaries and/or a career advancement policy. Notwithstanding the positive impacts of Public Health implemented in these countries, the crisis faced by the globalized economy may significantly undermine this strategy, thus worsening the population’s health situation.⁸8. Lee H, Kim S, DeMarco R, Aronowitz T, Mtengezo J, Kang Y, et al. Recognizing global disparities in health and in health transitions in the 21st century: what can nurses do? Appl Nurs Res [Internet]. 2015 Feb [cited 2020 Mar 23];28(1):60-5. Available from: Available from: https://doi.org/10.1016/j.apnr.2014.09.004
https://doi.org/10.1016/j.apnr.2014.09.0...

In Brazil, the SUS workforce can be considered to be the system’s biggest challenge, principally due to political and legal decisions that facilitate the Health sector being opened to foreign capital, in addition to the proposal for a new privately managed SUS.⁹9. Rizzotto MLF, Campos GWS. O Banco Mundial e o Sistema Único de Saúde brasileiro no início do século XXI. Saúde Soc [Internet]. 2016 jun [citado 2020 mar 23];25(2):263-76. Disponível em: Disponível em: https://doi.org/10.1590/S0104-12902016150960
https://doi.org/10.1590/S0104-1290201615... All of this implies redimensioning SUS human resources, as made evident in a document produced by the Ministry of Health: human resources approached as a priority strategy for achieving a democratic, equitable and efficient health system.¹⁰10. Ministério da Saúde (BR). Secretaria de Políticas de Saúde. Política de recursos humanos para o SUS: balanço e perspectivas [Internet]. Brasília: Ministério da Saúde ; 2003 [citado 2018 ago 10]. 31 p. Disponível em: Disponível em: http://livroaberto.ibict.br/bitstream/1/886/1/politica_recursos_humanos_SUS.pdf
http://livroaberto.ibict.br/bitstream/1/...

Although the health policy prioritizes the organization of multi-professional teams, high personnel turnover, especially of doctors and nurses, has caused discontinuity and fragmentation of the care they provide.¹¹11. Medeiros CRG, Junqueira AGW, Schwingel G, Carreno I, Jungles LAP, Saldanha OMFL. A rotatividade de enfermeiros e médicos: um impasse na implementação da Estratégia de Saúde da Família. Ciênc Saúde Coletiva [Internet]. 2010 jun [citado 2020 mar 23];15(Suppl 1):1521-31. Disponível em: Disponível em: https://doi.org/10.1590/S1413-81232010000700064
https://doi.org/10.1590/S1413-8123201000... In the face of the new barriers to the sustainability of a universal and equitable SUS concerned with its workforce as a priority, it is fitting and relevant to examine the spatial distribution and temporal trend of human resources, both in the SUS and in the Supplemental Health sector. Despite the significant presence of studies in this area,¹²12. Carvalho MN, Gil CRR, Costa EMOD, Sakai MH, Leite SN. Needs and dynamics of the primary healthcare workforce in Brazil. Ciênc Saúde Coletiva [Internet]. 2018 Jan [cited 2020 Mar 23];23(1):295-302. Available from: Available from: https://doi.org/10.1590/1413-81232018231.08702015
https://doi.org/10.1590/1413-81232018231... few seek to provide evidence of this dialectic situation. The objective of this study was to analyze the spatial distribution and temporal trend of SUS and Supplementary Health Sector human resources in Brazil.

Methods

This was an ecological study¹³13. Rothman KJ, Lash TL, Greenland S. Modern epidemiology. 3. ed. Filadelfia: Lippincot Williams & Wilkins; 2008. conducted in Brazil. Its units of analysis were the country’s 27 Federative Units (FUs), namely: 26 states and the Federal District.

According to the Demographic Census conducted by the Brazilian Institute of Geography and Statistics (IBGE) in 2010, Brazil had a population of 190,755,799 inhabitants, a Gini index of 0.6086, gross domestic product (GNP) of BRL 3,885,847,002.9 and average per capita household income of BRL 767.02, an unemployment rate of 13.1% and 34.7% of the population with income below half a minimum wage that year.¹⁴14. Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2010 [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2010 [citado 2018 ago 5]. Disponível em: Disponível em: https://censo2010.ibge.gov.br/resultados.html
https://censo2010.ibge.gov.br/resultados...

Data were compiled in relation to the following personnel categories available for health care in Brazil: doctors, dental surgeons, nurses and nursing technicians, for both the SUS and the Supplemental Health sector. The data source used was the National Health Establishment Registry (CNES), available via the Health Ministry SUS Information Technology Department (DATASUS) website.

The coverage rates provided by the health personnel categories were calculated by taking the number of health personnel in each specific category (numerator) and the total resident population (denominator), for each FU, adjusted for mid-year, multiplied by 1,000 inhabitants.

The Prais-Winsten¹⁵15. Antunes JLF, Cardoso MRA. Uso da análise de séries temporais em estudos epidemiológicos. Epidemiol Serv Saúde [Internet]. 2015 jul-set [citado 2020 mar 23];24(3):565-76. Disponível em: Disponível em: https://doi.org/10.5123/S1679-49742015000300024
https://doi.org/10.5123/S1679-4974201500... generalized linear analysis model was used for the temporal trend analysis, where the years assessed (2005-2016) were the independent variables (X) and the coverage rates of the health personnel categories were the dependent variables (Y). The straight line of best fit between the points on the time series, the trend of which was to be estimated, was defined according to the following equation:

where:

Y: times series value

X: timescale

The Prais-Winsten auroregressive model is indicated for correcting autocorrelation in time series.¹⁵15. Antunes JLF, Cardoso MRA. Uso da análise de séries temporais em estudos epidemiológicos. Epidemiol Serv Saúde [Internet]. 2015 jul-set [citado 2020 mar 23];24(3):565-76. Disponível em: Disponível em: https://doi.org/10.5123/S1679-49742015000300024
https://doi.org/10.5123/S1679-4974201500...

In order to reduce variance heterogeneity of temporal regression analysis residuals, logarithmic transformation (log10) was applied to the Y values.¹⁵15. Antunes JLF, Cardoso MRA. Uso da análise de séries temporais em estudos epidemiológicos. Epidemiol Serv Saúde [Internet]. 2015 jul-set [citado 2020 mar 23];24(3):565-76. Disponível em: Disponível em: https://doi.org/10.5123/S1679-49742015000300024
https://doi.org/10.5123/S1679-4974201500... Personnel coverage rates were calculated using Excel, while temporal trend analysis was performed using STATA 13.

As a result of this analysis, the annual growth rates (AGR) of the personnel categories and respective 95% confidence intervals (95%CI) were obtained. Temporal trend is considered to be falling if both of the confidence interval values are negative; rising if these values are positive; and stationary when the confidence interval crosses zero, i.e. the lower limit and the upper limit have opposite signs.¹⁵15. Antunes JLF, Cardoso MRA. Uso da análise de séries temporais em estudos epidemiológicos. Epidemiol Serv Saúde [Internet]. 2015 jul-set [citado 2020 mar 23];24(3):565-76. Disponível em: Disponível em: https://doi.org/10.5123/S1679-49742015000300024
https://doi.org/10.5123/S1679-4974201500...

With regard to the spatial distribution stage, the shapefile for Brazil was obtained from the IBGE website and ArcGIS version 10.6 was used to produce maps of human resource coverage and point density per km².

Results

Table 1 shows the AGR and the 95%CI for the number of doctors and dental surgeons per inhabitant, for those providing services for the SUS or for the Supplemental Health sector.

With regard to doctors, when analyzing those providing services for the SUS, it can be seen that the states of Maranhão (-0.01 - 95%CI -0.02;-0.00), Piauí (-0.02 - 95%CI -0.03;-0.01), Paraíba (-0.02 - 95%CI -0.03;-0.00), Alagoas (-0.02 - 95%CI -0.03;-0.00), Bahia (-0.02 - 95%CI -0.03;-0.00) and Mato Grosso (-0.01 - 95%CI -0.03;-0.00) had a falling trend, while the remaining states showed a stationary trend in the number of personnel available to provide services to the population. With regard to doctors providing services to the Supplemental Health sector, it was found that the states of Amapá (-0.04 - 95%CI -0.07;0.00), Maranhão (0.00 - 95%CI -0.01;0.02), Rio Grande do Norte (-0.01 - 95%CI -0.03;0.00), Paraíba (0.00 - 95%CI -0.00;0.01) and Espírito Santo (0.01 - 95%CI -0.01;0.03) had a stationary trend, while there was a rising trend in the number of these personnel in the remaining FUs.

Regarding dental surgeons working for the SUS, 11 FUs had a stationary temporal trend, 14 had a rising trend and only the Federal district and Santa Catarina had a falling trend. With regard to dental surgeons working for the Supplemental Health sector, only the Federal District had a stationary trend (0.01 - 95%CI -0.02;0.03); there was a rising trend in the number of personnel in all the other FUs.

As for nurses (Table 2), in relation to the SUS, there was a rising trend in the states of Rondônia (0.03 - 95%CI 0.01;0.05), Roraima (0.04 - 95%CI 0.02;0.06), Tocantins (0.04 - 95%CI 0.02;0.06), Minas Gerais (0.03 - 95%CI 0.01;0.05), Espírito Santo (0.03 - 95%CI 0.00;0.05), Rio de Janeiro (0.03 - 95%CI 0.02;0.05), São Paulo (0.02 - 95%CI 0.01;0.03), Rio Grande do Sul (0.02 - 95%CI 0.00;0.04), Mato Grosso do Sul (0.04 - 95%CI 0.01;0.06) and the Federal District (0.02 - 95%CI 0.01;0.03). The trend was stationary in the remaining FUs.

In the Supplemental Health sector, the trend for the number of nurses was stationary in the states of Amapá (-0.04 - 95%CI -0.10;0.02), Maranhão (0.00 - 95%CI -0.01;0.02) and Piauí (0.02 - 95%CI -0.01;0.05); while there was a falling trend in Rio Grande do Norte (-0.04 - 95%CI -0.08;-0.01) (Table 2).

When analyzing SUS nursing technicians, it can be seen that all UFs had a rising trend. With regard to nursing technicians in the Supplemental Health sector, the states of Acre (-0.03 - 95%CI -0.23;0.19), Amapá (-0.00 - 95%CI -0.07;0.06), Piauí (-0.00 - 95%CI -0.04;0.04), Rio Grande do Norte (-0.02 - 95%CI -0.06;0.02) and Paraíba (0.00 - 95%CI -0.01;0.01) showed a stationary trend. A rising trend was found in the remaining states for this personnel category (Table 2).

Figure 1 shows the spatial distribution of SUS and Supplemental Health human resources in the FUs for the year 2013. Doctors were concentrated in the South and Southeast regions of the country and in the case of the SUS, there were between 2.21 and 2.99 doctors per 1,000 inhabitants. Disparity was found in the distribution of these professionals over the national territory; especially in the states of Amazonas, Pará, Amapá and Maranhão, where SUS doctor coverage was much lower, i.e. between 0.01 and 1.25 professionals per 1,000 inhabitants. With regard to the Supplemental Health sector, the FUs with most doctors available were Santa Catarina, Espírito Santo and the Federal District.

Differently to doctors, distribution of SUS nurses was homogenous throughout the country. These professionals were most available in the state of Rio de Janeiro and in the Federal District, where coverage per 1,000 inhabitants was between 0.93 and 1.10. In the Supplemental Health sector, the largest numbers of nurses were found in the Federal District, Rio de Janeiro and São Paulo.

Heterogeneous distribution among the FUs was found for both SUS and Supplemental Health sector nursing technicians. This disproportionality was greater in the SUS: the availability of these professionals was disproportional between states within the same macro-region. In the Supplemental Health sector, nursing technicians were more concentrated in the South and Southeast regions of the country.

With regard to SUS dental surgeons, greater availability was found in the states of Paraíba and Mato Grosso do Sul, while in the Supplemental Health sector these professionals were concentrated in the South and Southeast regions and in the Federal District.

Figure 2 shows the spatial distribution of SUS and Supplemental Health sector health personnel availability for the year 2016. Comparing the 2016 data with the 2013 data (Figure 1), in the SUS there was only a change in doctors in the state of Paraíba, where their availability reduced, and in the state of Roraima, where coverage increased, between the two years of the period under consideration. With regard to the Supplemental Health sector, availability of doctors increased in the South, Southeast and Midwest.

In the case of SUS and Supplemental Health sector nurses, in 2016 spatial distribution of coverage was similar to that found in 2013, with availability of these personnel possibly being stationary. In 2016, distribution of SUS nursing technicians apparently continued to be heterogeneous throughout the country. The states of Amapá, Tocantins, Rondônia and Paraná had between 2.49 and 3.69 nursing technicians per 1,000 inhabitants. Regarding the Supplemental Health sector, nursing technicians were most available in the state of Espírito Santo and in the Federal District: coverage of between 0.56 and 0.87 (Figure 2).

SUS dental surgeons also had heterogeneous distribution in 2016, being concentrated in the states of Paraíba, Piauí, Tocantins and Mato Grosso do Sul. In the case of the Supplemental Health sector, the Federal District and the states of Paraná and Santa Catarina had the greatest availability. The Federal District stands out in that it was one of the FUs with lowest SUS dental surgeon coverage, while Supplemental Health sector dental surgeon coverage was among the highest in the country that year (Figure 2).

Figure 3 shows the density of doctors, dental surgeons, nurses and nursing technicians in Brazil between 2013 and 2016. Each point on the maps represents one health professional per 1,000 inhabitants. It can be seen that the North and Midwest regions had the lowest density for all personnel categories and that the growth rate was lower in the period from 2013 to 2016.

Discussion

Distribution of the number of SUS and Supplemental Health sector human resources in the personnel categories studied was found to be unequal. Between 2005 and 2016, no rising trend for SUS doctors was seen, differently to the Supplemental Health sector, where trends rose in the majority of FUs. In general, SUS dental surgeons, nurses and nursing technicians showed trends that varied between stationary and rising. With regard to these personnel categories in the Supplemental Health sector, generally speaking the trends were rising.

It should be emphasized that the Supplemental Health sector comprises the private healthcare insurance market, consisting of medical work cooperatives, dental cooperatives, group medicine companies, self-management groups and insurance companies.¹⁶16. Malta DC, Stopa SR, Pereira CA, Szwarcwald CL, Oliveira M, Reis AC. Cobertura de planos de saúde na população brasileira, segundo a Pesquisa Nacional de Saúde, 2013. Ciênc Saúde Coletiva [Internet]. 2017 [citado 2020 mar 23];22(1):179-90. Disponível em: Disponível em: https://doi.org/10.1590/1413-81232017221.16782015
https://doi.org/10.1590/1413-81232017221... the Supplemental Health sector has expanded in Brazil since the SUS was consolidated: in the 1990s its coverage related to 18.2% of the general population while in 2016 it was 24.9% and the forecast is for a rising trend - depending on current political circumstances, measures to open the Public Health sector to foreign capital and approval of the bill of law to outsource activities that could be done internally.¹⁷17. Ziroldo RR, Gimenes RO, Castelo Júnior C. A importância da saúde suplementar na demanda da prestação dos serviços assistenciais no Brasil. Mundo Saúde [Internet]. 2013 [citado 2020 mar 23];37(2):216-21. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/artigos/mundo_saude/importancia_saude_suplementar_demanda_prestacao.pdf
http://bvsms.saude.gov.br/bvs/artigos/mu...

Another relevant point relates to the national panorama of political and economic crisis. In 2016, approximately 12 million Brazilians were unemployed, thus reducing the possibility of paying for private health insurance. Given the context of less health insurance being taken out, the population’s demand for SUS healthcare will be increasingly greater. However, this demand will not be duly met by an increase in supply of services and real expansion of the SUS, this being limited above all by the restrictive measures imposed by CA 95.²2. Reis AAC, Sóter APM, Furtado LAC, Pereira SSS. Tudo a temer: financiamento, relação público e privado e o futuro do SUS. Saúde Debate [Internet]. 2016 dez [citado 2020 mar 23];40(spe):122-35. Disponível em: Disponível em: https://doi.org/10.1590/0103-11042016s11
https://doi.org/10.1590/0103-11042016s11...

Nunes et al.¹⁸18. Nunes BP, Flores TR, Garcia LP, Chiavegatto Filho ADP, Thumé E, Facchini LA. Tendência temporal da falta de acesso aos serviços de saúde no Brasil, 1998-2013. Epidemiol Serv Saúde [Internet]. 2016 out-dez [citado 2020 mar 23];25(4):777-87. Disponível em: Disponível em: https://doi.org/10.5123/s1679-49742016000400011
https://doi.org/10.5123/s1679-4974201600... found a rising trend in the population’s demand for SUS health services in most of the country’s macro-regions. Furthermore, their study highlights that the rural population’s demand for access is greater when compared to the urban population. This phenomenon is more intense when people have multiple comorbidities. The results of our study provide evidence of a critical node, in terms of human resources for Health in Brazil, particularly with regard to doctors, whose priority is concentrated on the Supplemental Health sector.

Malta et al.,¹⁶16. Malta DC, Stopa SR, Pereira CA, Szwarcwald CL, Oliveira M, Reis AC. Cobertura de planos de saúde na população brasileira, segundo a Pesquisa Nacional de Saúde, 2013. Ciênc Saúde Coletiva [Internet]. 2017 [citado 2020 mar 23];22(1):179-90. Disponível em: Disponível em: https://doi.org/10.1590/1413-81232017221.16782015
https://doi.org/10.1590/1413-81232017221... in their description of health insurance coverage in Brazil according to sociodemographic characteristics, and comparison with administrative data produced by the National Supplemental Health Agency (ANS) in 2017, found that for Brazil as a whole 27.9% of respondents reported having some kind of health insurance. Moreover, the populations of the country’s Southeast and Northern regions have the highest and the lowest health insurance coverage, respectively, corroborating the data of our study - in which the only state where the Supplemental Health sector did not show a rising trend was the state of Acre (Northern Brazil).

Our findings provide evidence of a decrease in doctors providing services to the SUS in the same FUs, this result being similar to that of the study entitled ‘Medical Demography in Brazil 2015’.¹⁹19. Scheffer M (Org.). Demografia médica no Brasil 2015 [Internet]. São Paulo: Departamento de Medicina Preventiva, Faculdade de Medicina da USP; Conselho Regional de Medicina do Estado de São Paulo; Conselho Federal de Medicina; 2015 [citado 2020 mar 23]. 284 p. Disponível em: Disponível em: http://www.usp.br/agen/wp-content/uploads/DemografiaMedica30nov2015.pdf
http://www.usp.br/agen/wp-content/upload... The More Doctors Program (Programa Mais Médicos - PMM), created by the federal government in 2013, recruited 14,462 Brazilian and foreign doctors allocated to 3,785 of the country’s municipalities. When comparing the distribution of doctors with the quantity of municipalities with an incipient number of this personnel category in Primary Health Care, it was found that the number of municipalities went down from 1,200 in March 2013 to 558 in 2014, this being the equivalent of a 53.5% reduction in the number of professionals available in this category.²⁰20. Collar JM, Almeida Neto JB, Ferla AA. Formulação e impacto do Programa Mais Médicos na atenção e cuidado em saúde: contribuições iniciais e análise comparativa. Saúde Redes [Internet]. 2015 [citado 2020 mar 23];1(2):43-56. Disponível em: Disponível em: http://dx.doi.org/10.18310%2F2446-4813.2015v1n2p43-55
http://dx.doi.org/10.18310%2F2446-4813.2...

In the Northern region, 91.2% of the municipalities that had limited access to doctors in 2013 were provided with 4.9 PMM doctors per municipality on average (the greatest proportion compared to the country’s other regions).²¹21. Estação de Pesquisa de Sinais de Mercado. Dados estatísticos sobre o impacto do Programa Mais Médicos no cenário de escassez de médicos em atenção primária no Brasil [Internet]. Belo Horizonte: EPSM/NESCON/FM/UFMG; 2015 [citado 2018 ago 5]. Disponível em: Disponível em: http://epsm.nescon.medicina.ufmg.br/epsm/Pesquisa_Andamento/Impacto_Programa_Mais_Medicos.pdf
http://epsm.nescon.medicina.ufmg.br/epsm... Despite the increase in the number of doctors thanks to the More Doctors Program, the trend for the number of these professionals working for SUS continued to fall. This reflects the preference of these professionals for working for the Supplemental Health sector, including for salary-related issues and the attractiveness of the market and liberal medicine.

An emblematic issue in the SUS is the turnover of Family Health Strategy (ESF) personnel. Strategic losses, disruption and lack of identification with the team, as well as harm caused to the cost-effectiveness and organizational efficacy of the service,²²22. Tonelli BQ, Leal APR, Tonelli WFQ, Veloso DCMD, Gonçalves DP, Tonelli SQ. Rotatividade de profissionais da Estratégia Saúde da Família no município de Montes Claros, Minas Gerais, Brasil. RFO UPF [Internet]. 2018 out [citado 2020 mar 23];23(2):180-5. Disponível em: Disponível em: https://doi.org/10.5335/rfo.v23i2.8314
https://doi.org/10.5335/rfo.v23i2.8314... in addition to affecting linkage with the population, have prevented the expected results from being achieved.²³23. Pierantoni CR, Vianna CMM, França T, Magnago C, Rodrigues MPS. Rotatividade da força de trabalho médica no Brasil. Saúde Debate [Internet]. 2015 set [citado 2020 mar 23];39(106):637-47. Disponível em: Disponível em: https://doi.org/10.1590/0103-110420151060003006
https://doi.org/10.1590/0103-11042015106... A large part of the challenges and difficulties permeating the scaling-up and enhancement of the ESF arises from shortage and turnover of these professionals, especially in cities in the interior, in the North and Northeast regions and in risk areas in the poor outskirts of large towns and cities.¹⁶16. Malta DC, Stopa SR, Pereira CA, Szwarcwald CL, Oliveira M, Reis AC. Cobertura de planos de saúde na população brasileira, segundo a Pesquisa Nacional de Saúde, 2013. Ciênc Saúde Coletiva [Internet]. 2017 [citado 2020 mar 23];22(1):179-90. Disponível em: Disponível em: https://doi.org/10.1590/1413-81232017221.16782015
https://doi.org/10.1590/1413-81232017221...

Getting professionals to stay in the ESF is a huge challenge for the sustainability of a universal health system, where Primary Health Care is the main point of entry, as well as being a huge challenge for coordination, continuity, family health education, community linkage and guidance.²⁴24. White F. Primary health care and public health: foundations of universal health systems. Med Princ Pract [Internet]. 2015 Jan [cited 2020 Mar 23];24(2):103-16. Available from: Available from: https://doi.org/10.1159/000370197
https://doi.org/10.1159/000370197... The systems that adopt the ESF have produced results with greater impact in terms of equity, access, service user satisfaction and the population’s quality of life.²⁵25. Prates ML, Machado JC, Silva LS, Avelar PS, Prates LL, Mendonça ET, et al. Desempenho da Atenção Primária à Saúde segundo o instrumento PCATool: uma revisão sistemática. Ciênc Saúde Coletiva [Internet]. 2017 jun [citado 2020 mar 23];22(6):1881-93. Disponível em: Disponível em: https://doi.org/10.1590/1413-81232017226.14282016
https://doi.org/10.1590/1413-81232017226... In the case of dental surgeons, the findings of this study point to a rising trend in the availability of these professionals, both in the SUS and in the Supplemental Health sector. In 14 FUs, the number of dental surgeons working in the SUS was rising, it was stationary in 11 FUs, and was only falling in the Federal District and Santa Catarina. On the other hand, in the Supplemental Health sector the same trend was only stationary in the Federal District and was rising in all the states. This also indicates dental surgeon preference for working in the Supplemental Health sector.

In order to increase the population’s access to oral health and, in this way, encourage Primary Health Care action reorganization, in the year 2000 the Ministry of Health proposed the inclusion of Oral Health teams as part of the ESF, with the overriding objective of improving oral health epidemiological indices and increasing the Brazilian population’s access to this form of health care.²⁶26. Correa GT, Celeste RK. Associação entre a cobertura de equipes de saúde bucal na saúde da família e o aumento na produção ambulatorial dos municípios brasileiros, 1999 e 2011. Cad Saúde Pública [Internet]. 2015 dez [citado 2020 mar 23];31(12):2588-98. Disponível em: Disponível em: https://doi.org/10.1590/0102-311X00000915
https://doi.org/10.1590/0102-311X0000091...

The National Oral Health Policy has driven improvement of the oral health care process, so as to leave behind the traditional model characterized by ‘preventivism’ in collective actions aimed exclusively at school children, for example, and by mutilative clinical actions. In view of this, a more positive result is expected for the use of public dental services in Brazil.²⁶26. Correa GT, Celeste RK. Associação entre a cobertura de equipes de saúde bucal na saúde da família e o aumento na produção ambulatorial dos municípios brasileiros, 1999 e 2011. Cad Saúde Pública [Internet]. 2015 dez [citado 2020 mar 23];31(12):2588-98. Disponível em: Disponível em: https://doi.org/10.1590/0102-311X00000915
https://doi.org/10.1590/0102-311X0000091...

With regard to SUS nurses, the results of this study showed a stationary trend in the number of these professionals in 17 states, whereas in the Supplemental Health sector this number rose in the majority of FUs and only fell in Rio Grande do Norte, differently to nursing technicians who increased in both the SUS and the Supplemental Health sector. The Institute of Applied Economic Research (IPEA), a foundation linked to the Ministry of the Economy, revealed that ‘nurses and akin’ were in second place among the careers that most grew in terms of numbers of work positions between January 2009 and December 2012.²⁷27. Oliveira JSA, Pires DEP, Alvarez AM, Sena RR, Medeiros SM, Andrade SR. Trends in the job market of nurses in the view of managers. Rev Bras Enferm [Internet]. 2018 Jan-Feb [cited 2020 Mar 23];71(1):148-55. Available from: Available from: https://doi.org/10.1590/0034-7167-2016-0103
https://doi.org/10.1590/0034-7167-2016-0... The majority of SUS nurses and nursing technicians are allocated to the ESF, which, since 2004, works with teams comprised of a doctor, a nurse, a nursing auxiliary or technician and at least four community health agents, as well as oral health professionals.²⁸28. Ministério da Saúde (BR). Portaria MS/GM n. 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS) [Internet]. Diário Oficial da União, Brasília (DF), 2011 out 21 [citado 2020 mar 23];Seção 1:48. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2488_21_10_2011.html
http://bvsms.saude.gov.br/bvs/saudelegis... Studies demonstrate that ESF coverage has increased for the Brazilian population, reaching 53.4% in 2013.¹⁶16. Malta DC, Stopa SR, Pereira CA, Szwarcwald CL, Oliveira M, Reis AC. Cobertura de planos de saúde na população brasileira, segundo a Pesquisa Nacional de Saúde, 2013. Ciênc Saúde Coletiva [Internet]. 2017 [citado 2020 mar 23];22(1):179-90. Disponível em: Disponível em: https://doi.org/10.1590/1413-81232017221.16782015
https://doi.org/10.1590/1413-81232017221... However, in terms of human resources, the rising trend in nursing technicians was greater than that found for nurses. This may suggest imbalance in ESF teams.

The increase in the number of nursing technicians probably reflects Federal Nursing Council (COFEN) Resolution No. 276/2003, which determined that registration with COFEN would only be granted to professionals in this category who have qualified at the Nursing Auxiliary stage as part of the Nursing Technician Professional Education Course. As a result, an increase in the trend of these professionals can be seen in all the Federative Units, both in providing services to the SUS and also to the Supplemental Health sector.²⁹29. Bógus CM, Bersusa AAS, Martins CL, Escuder MML. Conhecendo egressos do curso técnico de Enfermagem do PROFAE. Rev Esc Enferm [Internet]. 2011 ago [citado 2020 mar 23];45(4):945-52. Disponível em: Disponível em: https://doi.org/10.1590/S0080-62342011000400022
https://doi.org/10.1590/S0080-6234201100...

With regard to doctors, the states with the poorest increasing trends for these professionals are located in the Country’s North and Northeast regions, possibly due to lack of desired local infrastructure which is propitious to turnover, apart from them being less socio-economically developed regions, where there are few professional training institutions.³⁰30. Linhares PHA, Lira GV, Albuquerque IMN. Avaliação do Programa de Melhoria do Acesso e Qualidade no estado do Ceará. Saúde Debate [Internet]. 2014 out [citado 2020 mar 23];38(spe):195-208. Disponível em: Disponível em: https://doi.org/10.5935/0103-1104.2014S015
https://doi.org/10.5935/0103-1104.2014S0...

Rio Grande do Norte was the only state where there was a falling trend in nurses in the Supplemental Health sector, unlike the majority of the states and the Federal District where there were rising trends. According to Oliveira et al.,²⁷27. Oliveira JSA, Pires DEP, Alvarez AM, Sena RR, Medeiros SM, Andrade SR. Trends in the job market of nurses in the view of managers. Rev Bras Enferm [Internet]. 2018 Jan-Feb [cited 2020 Mar 23];71(1):148-55. Available from: Available from: https://doi.org/10.1590/0034-7167-2016-0103
https://doi.org/10.1590/0034-7167-2016-0... several factors are related to the decrease in the number of nurses working in Rio Grande do Norte, ranging from lack of opportunities for many people finishing training school, to those who seek jobs without having experience or being qualified, and to job insecurity in the private sector or in the SUS, as a result of short-term employment contracts, resulting in periodical personnel turnover, as well as instability and discontinuity in the care provided.

This study has limitations related to its ecological design, as well as the use of secondary data and consequent risk of bias given the incompleteness or frequency of missing information in the DATASUS database on which this study was based.

The falling or stationary trend of SUS health professionals between 2005 and 2016 is cause for concern. It may reflect negatively on the ability of SUS to carry out its health actions and services, making it less apt and weakening it in relation to the social mission it has to fulfill, its prospective vision and the preservation of its values. The Brazilian health system crisis may lead to unequal access to health care, with significant impact on vulnerable populations. It is essential to promote human resources and increasingly integrate them into the permanent process of creating, reinventing and adapting Public Health structures, in defense of more equitable health care in line with the civil rights of those who use the Brazilian National Health System.

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