Trends in Labor Contracting in Brazil's Family Health Program

Human Resources for Health Observatory - Federal University of Minas Gerais
http://www.observarh.org.br/epsm
Trends in Labor Contracting in the
Family Health Program in Brazil
Sabado Nicolau Girardi
Cristiana Leite Carvalho
Health Human Resources Observatory -
Federal University of Minas Gerais
12th World Congress on Public Health
Istanbul, Turkey, April 27 – May 1, 2009

Objective
• This study analyses the pattern of contracting work and
quality of jobs created and sustained by the Health
Family Program over five years (2001-2006) in order to
identify the main changes in this segment of the health
labor market.
– Contracting in and out are dimensioned as well as the utilization
of standard and nonstandard employment relations.
– The reasons attributed by the public managers for contracting
protected and unprotected labor are investigated.

Family Health Program
• The Family Health Program is the national strategy to reordenate
brazilian health care system and to delivery primary care.
• The standard FHP team is composed of 1 physician, 1 nurse, 1 nursing
assistant, 6 community health agents, 1 dentist, 1 dental assistant, 1
dental hygienist.
• Each team is responsible for 1,000 families.
• It covers 90 million people (47% of Brazilian population).
• It is mostly financed by the federal government.
• The recruitment, contract and payment of the health workforce are on
the local government hands.
• It employs 400 thousand health workers.

• Between 2001-2006, there have been positive results on
the health labor market due to the HFP, such as an
increase in employment offer and workers’ income.
• There have also been some negative issues related to
the spread of labor “precariousness”.
– Spread of precarious contract arrangements: violation of labor
rights and rules.
– Legal questions related to contracting out in the public sector.

Methodology
• The data of two national surveys carried out in a sample
of Brazilian municipalities in 2001 (759 municipalities)
and 2006 (855 municipalities) were analyzed.
• Both surveys collected data on contracting and
remuneration of physicians, dentists, nurses, nurse
assistants and community health agents.
• The data were collected through computer-assisted
telephone interviews (CATI) with local governmental
managers or human resource managers.

Analytical Categories
• Direct contracting: when the contract is hold directly by
the local government.
• Contracting out: when the local government contracts
health workers through private organizations (profit or not
for profit) and autonomous or decentralized public
organizations.
• Protected jobs: when jobs have legal support, social
protection including labor and social rights and time
indeterminacy of the contract.
• Unprotected jobs: when jobs share the absence of
standard labor and social rights as well as instability and
insecurity.

In general terms, we can say that for the country as a whole,
contracting out has a relatively low rate, being higher in
contracting ACS (Health Community Agents).
0
10
20
30
40
50
60
70
80
90
Physicians Nurses Dentists Nurse
Assistants
ACS
Directed Contract vs. Contracting Out in PSF 2006
Direct Contracting
Contracting Out
Results

Contracting Out
0
5
10
15
20
25
30
Assistants
ACS
2001
2006
Contrary to some expectations, the data shows that the level of
contracting out by the local governments has decreased all over
the country.

0
10
20
30
40
50
60
70
80
Assistants
ACS
Protected vs. Unprotected Jobs in PSF 2006
Protected Jobs
Unprotected Jobs
In spite of the low rates of contracting out labor, the data
report high levels of utilization of employment relationships
characterized as unprotected jobs.

Unprotected Jobs
0
10
20
30
40
50
60
70
80
90
Assistants
ACS
2001
2006
Trends in the use of unprotected labor in HFP 2001-2006
Between 2001 and 2006 there was a decrease in the utilization of
employment relationships characterized as unprotected jobs all
over the country.

Why contracting out and unprotected jobs?
• Numeric and functional flexibility – the ability to dismiss,
hire and relocate the workforce are reported as the
reason to use unprotected labor by around 40% of the
interviewees.
• Economic factors such as saving on indirect costs of
protected jobs or the possibility to offer physicians
higher salaries are stated by 20% of the municipalities.

• The existence of legal and administrative rules
constraining the employers’ behavior were considered
the main reason for contracting out by 30% of the
interviewees.
• Issues related to the financing sustentability are reported
by around 15% of the municipalities.
• Around 34% of the municipalities report the difficulty of
following the ritual formalities imposed by the Brazilian
laws for recruitment of civil servants as the reason for
employ unprotected health workers.

Conclusions
• The 2006 survey allowed concluding that there is still a
high level of non-compliance with legal requirements
when it comes to hiring professionals, even though,
when compared to the results of the 2001 survey, one
can find a reversion trend in this situation.
• A current survey, started 2009, is also showing that
compared to the results of the last one (2006), there
have been a continuing decrease in the utilization of
contracting out and of unprotected jobs in the Health
Family Program.

Trends in Labor Contracting in Brazil's Family Health Program

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