Trabalho em saúde Rede Colaborativa para Estudos Estratégicos da Força de Trabalho em Saúde no Brasil
Sabado Nicolau Girardi
Cristiana Leite Carvalho
The Family Health Program (PSF) is an important governmental intervention implemented in Brazil to improve primary health care by providing a comprehensive range of preventive and curative health care services delivered by a team composed of a physician, a nurse, a nurse assistant, and six community health workers. In addition, there is an oral health team composed of a dentist, a dental assistant, and a dental hygienist. Each team is responsible for the care of at least 1,000 families in a specific geographic area, usually consisting of about 3,000 to 4,500 people. The PSF has been developed as a strategy for the reorganization of the primary care system.
The PSF proposal was intended to have the teams take on responsibility for following up a given number of families who live in a specific area by promoting prevention, recovery, rehabilitation from the most frequent diseases and other illnesses, and health care in the given community. It is supported by principles such as integrality and quality of care, equality of access and community participation.
The PSF was started in 1994 with 328 teams introduced in 55 municipalities. Today, PSF is up and running in more than 5,100 of 5,564 municipalities across the country, with over 27,140 teams covering about 90 million people (47% of the Brazilian population). It is estimated that almost 400,000 health professional jobs are directly involved in the delivery of the program. In 2006, the Brazilian federal government invested about U$ 1.63 billion in this family health policy.
The program is mostly financed by the federal government with the participation of states and municipalities. The program management, including hiring, recruiting, and payment of the labor force, is the municipalities’ responsibility.
From its inception through today, the PSF has found many potentialities and challenges in Brazil. The potentialities have to do with the strategies aimed at dealing with the main problems in the health care model, which has strong access barriers and clear inequalities in the delivery of care. The program has had a major impact on the availability of primary health care. There have also been positive results such as an increase in both employment offers and workers’ incomes. The challenges include overcoming the spread of labor “precariousness” and hidden problems related to the contracting out of public health services.
From the perspective of the public labor unions, outsourcing and flexibility of employment relationships by the nation’s municipalities primarily take aim at evading labor rights and obligations, leading to instability and lack of protection for workers. Some segments of public management consider this type of contract to have a negative impact on the quality and continuity of health care. It makes the retention of qualified health workers difficult considering that legal aspects, labor courts, and public audit bodies have contested the legality of contracting out labor for the PSF. Contracts with public administration, which are not preceded by recruitment based on merit, have no legal and constitutional support. Besides, they also violate labor rights and obligations.
This paper analyzes contracting out and the kinds of labor relationships between the PSF and its workers in order to identify the main changes in the labor market for the program over the past five years. This period coincides with the first term of the present Brazilian federal government.