Monitoring Inequalities in the Health Workforce: The Case Study of Brazil 1991–2005

Introduction: Both the quantity and the distribution of health workers in a country are fundamental for assuring equitable access to health services. Using the case of Brazil, we measure changes in inequalities in the distribution of the health workforce and account for the sources of inequalities at sub-national level to identify whether policies have been effective in decreasing inequalities and increasing the density of health workers in the poorest areas between 1991 and 2005. Methods: With data from Datasus 2005 and the 1991 and 2000 Census we measure the Gini and the Theil T across the 4,267 Brazilian Minimum Comparable Areas (MCA) for 1991, 2000 and 2005 to investigate changes in inequalities in the densities of physicians; nurse professionals; nurse associates; and community health workers by states, poverty quintiles and urban-rural stratum to account for the sources of inequalities. Results: We find that inequalities have increased over time and that physicians and nurse professionals are the categories of health workers, which are more unequally distributed across MCA. The poorest states experience the highest shortage of health workers (below the national average) and have the highest inequalities in the distribution of physicians plus nurse professionals (above the national average) in the three years. Most of the staff in poor areas are unskilled health workers. Most of the overall inequalities in the distribution of health workers across MCA are due to inequalities within states, poverty quintiles and rural-urban stratum. Discussion: This study highlights some critical issues in terms of the geographical distribution of health workers, which are accessible to the poor and the new methods have given new insights to identify critical geographical areas in Brazil. Eliminating the gap in the health workforce would require policies and interventions to be conducted at the state level focused in poor and rural areas.