The rehabilitation workforce in Brazil | Archives of Public Health

Understanding the dynamics behind the growth of the rehabilitation workforce across Brazil’s three levels of care becomes pivotal as the demand for rehabilitation escalates. This comprehension encompasses insights into professionals’ availability, skill sets, motivations, performance, and geographical distribution [15].

There is no official recommendation on the ideal number of professionals to provide comprehensive care in rehabilitation6. However, Rehabilitation 2030: A Call for Action [5] pointed out that there is a shortage of qualified professionals, and thus rehabilitation care remains underserved.

Workforce needs and demands for rehabilitation are different in each local context. The capacity of the rehabilitation workforce in high-income countries is greater than in low- and middle-income countries. And even among high-income countries, the supply of professionals is highly variable, differing up to 40 times [16]. Jesus et al. reported densities of rehabilitation professionals ranging from < 0.01 per 10,000 population in low-income countries to up to 25 per 10,000 population in high-income countries [3]. Our results indicate densities of professionals in Brazil in 2020 closer to the rates of low-income countries.

In this study, we observed that the highest density of physical therapists in 2020 in Brazil was 2.17 professionals per 10,000 inhabitants. Different from the density in Ireland, which was 6.8 [17], but close to Canada, of 2.32 [18], and higher than Singapore, with 1.8 physiotherapists per 10,000 inhabitants [6]. As for psychologists, the density observed for Brazil was 1.42 professionals per 10,000 inhabitants, while the United States had 3.0 per 10,000 inhabitants [19]. The supply of speech therapists was 0.50 speech therapists per 10,000 inhabitants, values adjacent to South Africa [20] with a density of 0.57. As for occupational therapists, the density was 0.27 per 10,000 inhabitants, lower than the average of 0.9 in South Africa [21], 1.9 in Portugal [6] and 3.6 in the United States [6]. It is worth noting that this study considered only the professionals who provide services in health facilities of the Unified Health System.

The diversity within the rehabilitation workforce is accompanied by variability in practice scope and non-uniformity in data collection across studies, with some instances lacking available data [6, 16], Notably, most studies conducted their analyses based on absolute professional numbers without organization by healthcare levels, underscoring the importance of studies that delineate the specific placements of these professionals within the healthcare system. Such studies should standardize by workload to facilitate user access.

Within PHC, in the period studied, there was a significant upswing in rehabilitation professionals. A pivotal policy, likely contributing to this surge, was the creation of the Extended Family Health Center [22] that expanded the professional actions of primary care, including rehabilitation. The federal financial incentive to implement these teams – and the consequent expansion of PHC jobs – may have directly impacted the growth and supply of different professions that can compose the PHC teams, such as physical therapists, speech therapists, psychologists, and occupational therapists. However, the reorientation of the work process of the teams, introduced by the National Primary Care Policy [23] of 2017, as well as the change in funding in PHC, by Previne Brazil [24] in 2019, went in the opposite direction, and may compromise the expansion in the rehabilitation workforce. In this aspect, the findings of the study already indicate a reduction in the density of speech therapists as of 2018, as well as stabilization in the density of occupational therapists and deceleration in the growth of the other categories. These shifts in professional density might already reflect the impacts of these policies.

Between 2007 and 2020, the notable rise in the numbers of physical therapists, speech therapists, psychologists, and occupational therapists across the three levels of care reflects not just network expansion but also its increasing complexity. It underscores the establishment of policies specifically targeting care enhancement, such as the Care Network for People with Disabilities [25]. This network aimed to broaden access and improve the quality of care for individuals with diverse types of disabilities, whether temporary or permanent, progressive, regressive, or stable, addressing various disabilities, including those related to hearing, physical, intellectual, visual impairments, ostomy, and multiple disabilities.

The workforce growth, especially in SHC, peaked around 2012, the year of the important launch of two public policies that induce the creation and strengthening of specialized strategic services: the Specialized Rehabilitation Center for specialized outpatient care in rehabilitation that performs diagnosis, treatment, granting, adaptation and maintenance of assistive technology; and the Psychosocial Care Center, catering to people with psychic suffering or mental disorders, including those with needs arising from the use of alcohol, crack and other substances, who are in crisis situations or in psychosocial rehabilitation processes, as essential components of the Care Network for People with Disabilities [25] and Psychosocial Care Network [26].

Historically, rehabilitation actions have been executed within SHC [1]. This study underscores that, during the period analyzed, there was a greater concentration of professionals at this level of care, except for the physical therapists, who showed greater concentration in HHC. Rodes et al [4] also observed this situation in the period 2007–2015 and pointed out as a possible influence the Resolution nº 7, of February 24, 2010 [27], which establishes minimum standards for the functioning of Intensive Care Units, imposing the performance of at least one physiotherapist for every ten beds, 18 h a day. Among the benefits of the work of the physiotherapist in this area, are the reduction of mechanical ventilation time and the length of patient stay, reducing hospital costs [28]. The increase of physiotherapists in 2020 in HHC coincides with the first wave of Covid-19 deaths in Brazil. In that environment, the physiotherapist was fundamental to guarantee the monitoring of the patient’s respiratory mechanics.

The regional distribution of the rehabilitation workforce in Brazil presents disparities across different care levels. In Primary Health Care (PHC), the Northeast region displayed the highest densities of physical therapists, speech therapists, and occupational therapists. This can be attributed to its status as the region with the most comprehensive and well-distributed Family Health, Oral Health, and Expanded Family Health teams [29]. The expansion of rehabilitation actions in PHC is essential for long-term care, contributing to improve the quality of life of the population [2].

Regarding SHC, the Southern region concentrated the highest densities in all professional categories, while in PHC, the Southeast region had the largest workforce. The higher concentration of professionals in the South and Southeast is a historical issue in the country, justified by several factors, notably because they are areas with greater concentration of resources, technology, and educational institutions [30].

It is worth noting that inequalities in the geographic distribution of services and of the workforce is a worldwide problem, which demands strategies for the recruitment and retention of professionals to guarantee universal access to the population [31].

Public policies can direct more resources for the development of the health workforce. However, as pointed out by Silva et al. [32], it can be detrimental to witness an expansion in care provision followed by measures that undermine these efforts. For instance, the MS/GM Ordinance No. 3992/2017 [33] altered the transfer of resources for public health services, reducing funding blocks within the Unified Health System from six to two. Such shifts pose risks to both service and human resources expansion within the healthcare sector.

As a limitation of this study, we point out the use of secondary data with the possibility of incomplete information in the CNES [34], but this is the official database of the Brazilian Ministry of Health. The analyses were relativized for a weekly workload of 40 h, known as Full Time Equivalent, since professionals can have different workloads. Its use is beneficial in planning, monitoring, and comparing the health workforce, including between countries [35]. We specifically considered four professions that contribute to rehabilitation in the public health sector, but the insertion of other professional categories could broaden the discussion of health care in this area. Due to the absence of a current census, the estimated population was used based on data from the 2010 census.

Regional differences in the workforce compromise access to rehabilitation care for the most vulnerable populations. Although there is not a preconized number for the size of the workforce, studies point to the need to expand the supply of skilled labor in rehabilitation care [5]. In this sense, the identification of the rehabilitation workforce in Brazil is important to understand the distribution of professionals and what has occurred over the years. Moreover, the results may contribute to the planning of care management in rehabilitation, in order to provide better care and access to health services for the population.

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