Health work and education: policies, anti-politics and national challenges

Magnago, Carinne; Krugel, Camila de Carvalho; Tavares, Ana Verônica da Cunha

doi:10.1590/1413-81232026316.04212026

Abstract

Health systems depend on workers to ensure coverage and the right to health, but face global and national challenges related to education, employment and health workforce (FTS) performance. This work aims to analyze the policies and challenges faced by the FTS in Brazil, highlighting the influence of political contexts on the management of work and education in the Unified Health System (SUS). Based on a narrative review of national studies and documents, the text proposes a periodization of the trajectory of public policies in the area, categorized into: moment of antipolitics (1990-2002), moment of politics (2003-2015), return of antipolitics (2016 -2022) and policy resumption (2023-current). It is understood that government actions in response to social and collective demands shape the context in which the FTS operates. Public policies are not isolated entities; on the contrary, they reflect the social environment and involve complex negotiations of competing values, ideologies and interests.

Key words:
Health Workforce; Health Policy; Personnel Management

Resumo

Os sistemas de saúde dependem de trabalhadores para garantir a cobertura e o direito à saúde, mas enfrentam desafios globais e nacionais relacionados à educação, emprego e desempenho da força de trabalho em saúde (FTS). Este trabalho tem como objetivo analisar as políticas e desafios enfrentados pela FTS no Brasil, destacando a influência dos contextos políticos na gestão do trabalho e da educação no Sistema Único de Saúde (SUS). Baseado em uma revisão narrativa de estudos e documentos nacionais, o texto propõe uma periodização da trajetória de políticas públicas na área, categorizada em: momento de antipolítica (1990-2002), momento de política (2003-2015), retorno da antipolítica (2016-2022) e retomada da política (2023-atual). Entende-se que as ações do governo em resposta às demandas sociais e coletivas moldam o contexto em que a FTS opera. As políticas públicas não são entidades isoladas; ao contrário, refletem o ambiente social e envolvem negociações complexas de valores, ideologias e interesses em disputa.

Palavras-chave:
Gestão de Recursos Humanos em Saúde; Políticas públicas de saúde; Administração de recursos humanos

Resumen

Los sistemas de salud dependen de los trabajadores para garantizar la cobertura y el derecho a la salud, pero enfrentan desafíos globales y nacionales relacionados con la educación, el empleo y el desempeño del personal sanitario (FTS). Este trabajo tiene como objetivo analizar las políticas y los desafíos que enfrenta el Servicio Federal de Impuestos en Brasil, destacando la influencia de los contextos políticos en la gestión del trabajo y la educación en el Sistema Único de Salud (SUS). A partir de una revisión narrativa de estudios y documentos nacionales, el texto propone una periodización de la trayectoria de las políticas públicas en el área, categorizadas en: momento de la antipolítica (1990-2002), momento de la política (2003-2015), retorno de la antipolítica. (2016 -2022) y reanudación de la política (2023-actual). Se entiende que las acciones gubernamentales en respuesta a demandas sociales y colectivas moldean el contexto en el que opera el FTS. Las políticas públicas no son entidades aisladas; por el contrario, reflejan el entorno social e implican negociaciones complejas de valores, ideologías e intereses en competencia.

Palabras clave:
Administración de Personal; Política de Salud; Administración de Personal

Introduction

Health systems require workers to function. Improving health service coverage and realizing the right to the highest attainable standard of health depend on workers’ availability, accessibility, and quality. Countries at all socioeconomic levels face difficulties in educating, employing, attracting, retaining, and ensuring the performance of their health workforce (HWF), though to varying degrees. In some countries, chronic underinvestment in education and training, along with a mismatch between training and employment for health systems and population needs, has caused ongoing shortages. These issues are compounded by challenges in placing workers in rural, remote, and hard-to-reach areas. Some countries also have limited ability to absorb available health professionals, which leads to the paradox of unemployment among these professionals coexisting with major unmet health needs¹.

In Brazil, the context is similar. However, the three decades that followed the creation of the Unified Health System (SUS) were characterized by a sustained dynamism in the formulation of specific plans, strategies, and policies for the HWF aligned with global and regional priorities². This dynamism, however, did not occur in a linear fashion or without disputes. Especially in the 1990s, under neoliberal policies, an ‘anti-political’ movement led to precarious jobs and little government focus on the area. Thus, the Brazilian context must be understood as a field of tensions, in which significant institutional advances coexist, such as the construction of legal frameworks and guidelines for human resources in health (HRH), while at the same time facing structural and ideological restrictions that limit the materialization of these advances at the implementation level³.

This article examines work and education in health, showing how Brazil’s recent macropolitical strategies influenced the national context. It is grounded in national body studies and documents on the subject and the public policy analytical framework.

We immediately identify two periods following the creation of the SUS, regarding labor management and education in health policies, pointed out by Machado and Ximenes Neto⁴: the anti-politics period (1990-2002), marked by worker devaluation and avoidance of strengthening the field; and the politics period (2003-2015), beginning with the Secretariat for Labor Management and Health Education (SGTES), which formulated and implemented public policies who seek to comply with the legal provisions that place the responsibility for organizing training and coordinating human resources policies on the SUS. In this text, we add two periods more: a return to anti-politics from 2016 (Temer administration, deepened under Bolsonaro term 2018-2022), marked by policy rollbacks; and a politics resumption starting in 2023 with Lula’s return to the Presidency. We also review the years before SUS from the foundations that led to the inclusion of the topic of Human Resources in Health on the public agenda, and the field’s current challenges (Chart 1).

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Chart 1
Initiatives, strategies, and policy and anti-policy actions in health workforce management and health education in Brazil, 1986-2024.

Politics and anti-politics: conceptual foundations

Politics-and, therefore, anti-politics-is a polysemic concept, but, as human praxis, it is closely related to power. In the analytical field of public policy, politics is conceived as a government’s social response aimed at producing specific effects in response to the demands and problems of social groups and/or the broader community⁵^,⁶. It thus encompasses what the State does or fails to do under the influence and pressure of different stakeholders and through negotiations involving values, ideologies, opinions, and needs, expressing interests in dispute⁷^,⁸. From this perspective, no public policy is detached from the social context in which it is embedded and for which it is created, although it cannot address all demands/interests at once⁹.

Anti-politics runs counter to collective interests and is grounded especially-but not exclusively-in the interests of political elites and in deliberate depoliticization, mobilizing society in favor of neoliberal interests⁵. As understood in this study, the functional concept of politics presupposes the existence of a community whose members are aware of their mutual interdependence and internal differences, can act together, and are willing to accept authoritative decisions. Anti-political ideologies generally reject these premises. Instead of collectivity, plurality of interests and ideas, and political power, anti-politics proclaims self-regulating order, ideological uniformity, and individual needs and freedom⁶.

From this perspective, this article analyzes labor management and health education in Brazil over the last four decades. To understand State policies, it is not enough to analyze what is visible. It is also necessary to examine what is done, how, and why, all in the name of the State and its supposed rationality.

The initial foundations for the inclusion of labor and health education on the national public agenda

In Brazil, discussions about financing and organizing health services dominated public managers’ agendas for many years. Meanwhile, the HWF was viewed primarily as an extra resource and did not receive adequate recognition. The first National Health Conferences (CNS) covered the topic. The Third CNS (1963) highlighted the need for policies on recruiting, selecting, training, and best using technical professionals. The Fourth CNS (1967) focused discussions on HRH planning, essential for sectoral development¹⁰.

From the Eighth CNS (1986) onward, debates on HRH gained relevance. This started a structured process to organize the field and to define a specific agenda for analyzing HRH within the SUS implementation. The debates reflected diverse political viewpoints. Demands included fair pay, career and salary plans, ongoing training, public competitive exams, job stability, and multiprofessional teams¹⁰.

The Eighth CNS initially brought the formulation of a national HRH policy to the table. It introduced principles and proposals that were expanded at the First National Conference on Human Resources for Health (CNRHS) in October 1986. This event consolidated earlier analyses and set a strategic agenda for the sector during the Health Reform movement and the creation of a national health system¹¹.

With SUS implementation, new guidelines for action in the Health sector were necessary. The 1988 Federal Constitution called for HRH regulation. Law No. 8,080/1990 later reinforced this responsibility, assigning duties for HRH policy formulation and implementation to all government levels¹²^,¹³.

The anti-politics period (1990-2002): The lost decade for health workers

The 1990s were considered a “lost decade” for health workers⁴. SUS decentralization resulted in the expanded public service network, creating job opportunities at the local level. However, this period was also marked by State reforms oriented toward privatization, flexibilization, and deregulation, aggravating labor insecurity. These changes adversely affected workers and exposed the fragility of HWF management, which was unable to articulate regulatory policies with the demands of the prevailing neoliberal model¹⁴.

At the Ninth, Tenth, and Eleventh CNS, the challenges and proposals already established for the field were reiterated, since progress in overcoming the problems was limited. This reality consolidated HRH management as one of the most complex areas of the SUS and reinforced the need to restore it as a priority in public policies¹⁵.

During this period, the Tenth CNS was crucial. It led to drafting the principles and guidelines for an Operational Basic Norm for Human Resources for the SUS (NOB RH-SUS) in 1998. These guidelines were discussed and revised in the following years. Their content was fundamental for many later initiatives.

The politics period (2003-2015): Advancements in human resources policy for the SUS

In 2003, the area, previously under a general coordination office at the third tier of the Ministry of Health, became the responsibility of the newly created Secretariat for Labor Management and Health Education (SGTES). This change aimed to address persistent problems and establish clear policies for management and health education vital for the health system’s efficient functioning. At this time, the national HRH landscape included diverse forms of temporary contracts, lack of adequate career plans or worker dissatisfaction, insufficient remuneration, difficulties in retaining professionals, limits on staffing expansion imposed by the Fiscal Responsibility Law, lack of public competitive examinations, and a lack of continuing education programs¹⁴^,¹⁶.

Based on a positive agenda incorporating themes related to the principles and guidelines of the NOB/RH-SUS, over 15 years (2003-2018), the SGTES adopted several inducing strategies, with technical, political, and financial investments to improve management, producing significant impacts on the conduct of public health policies¹⁷^,¹⁸. Policies and programs were established for training and continuing education, for reducing labor insecurity, and for regulating, humanizing, and negotiating labor relations.

In 2003, the reinstatement of the National Permanent Negotiation Roundtable of the SUS (MNNP-SUS) promoted dialogue among managers, workers, and users, while the National Program for the Reduction of Labor Insecurity in the SUS (DesprecarizaSUS) sought to regularize labor ties, and the National Humanization Policy (HumanizaSUS) highlighted the importance of humanization in care and service management. The following year, the National Policy on Continuing Education in Health (PNEPS) integrated education and work, promoting the ongoing development of health teams. At the same time, programs such as SUS Immersion and Internship Experiences (VER-SUS), AprenderSUS, and EnsinaSUS drew students closer to the practical reality of the SUS, encouraging critical and reflective experiences¹⁹.

In the following years, the strengthening of professional training gained prominence through the National Program for the Reorientation of Professional Training in Health (Pró-Saúde), which sought to reorient curricula to meet SUS needs, and through the institutionalization of Multiprofessional Residency in Health, which emphasized interdisciplinary practice. From 2008 to 2010, initiatives such as the Program for Education through Work for Health (PET-Saúde), the Open University of the SUS (UNA-SUS), and the Program for the Training of Mid-Level Health Professionals (PROFAPS) prioritized training and continuing education to improve the HWF and integrate teaching and practice. In the same period, the National Scholarship Program for Residencies in the Professional Health Area (Pró-Residência) contributed to training medical experts in strategic areas, addressing regional shortages¹⁹^,²⁰.

Valuing professionals was also a focus during this period. The Program for the Valuation of Primary Care Professionals (PROVAB) (2011) encouraged doctors to work in hard-to-reach areas through benefits such as extra points for residency selection. In 2013, the More Doctors Program (PMM) expanded the presence of professionals in PHC, combining emergency provision with the expansion of seats in undergraduate medical education and residency, especially in Family and Community Medicine. In 2015, the Organizational Contracts for Public Teaching-Health Action (COAPES) became an instrument for formalizing partnerships between educational institutions and health services and, by integrating strategies for training and equitable distribution of professionals, contributed to greater equity and sustainability of the HWF in Brazil²¹^,²².

During this period, numerous advances were recorded despite some persistent challenges. In education, evidence pointed to fragmented undergraduate curricula, hindering interprofessional training and distancing programs from the National Curricular Guidelines. In addition, the PNEPS faced stagnation due to discontinuous financial transfers and technical support. In labor management, the perception that health workers were undervalued persisted, along with ongoing inequities in the availability and quality of the HWF²³^-²⁵.

Problems similar to those experienced by many countries, together with global initiatives led by the World Health Organization, motivated the Pan American Health Organization (PAHO) to approve, in 2017, the Human Resources for Health Strategy for Universal Access to Health, encouraging mechanisms to overcome HWF challenges, with a focus on the regulation and distribution of professionals. The Sustainable Health Agenda for the Americas 2018-2030 was also approved, establishing 11 objectives, including strengthening the management and development of HRH, aligned with the 2030 Agenda and the Human Resources for Health Strategy²⁶^-²⁸.

The return of anti-politics (2016-2022): the impact of counter-reforms on the SUS

In the period initiated by the parliamentary coup that removed Dilma Rousseff and elevated Michel Temer to the Presidency of the Republic, and ending with the close of the Bolsonaro administration, the Brazilian landscape moved away from the goals and aspirations of the agendas established for the Region of the Americas²⁹, revealing the advance of conservative forces opposed to this progress. New legislation and regulations weakened the health, education, and social security systems, resulting in cuts to social policy budgets, rising public debt, worsening poverty and hunger, and deepening social inequalities and violence. Society was affected by the dismantled social and environmental protection mechanisms and by fake news that contributed to disinformation and manipulation in the context of the health crisis caused by the COVID-19 pandemic³⁰.

Under the Temer administration, labor reform (Law No. 13,467/2017) was approved, expanding forms of hiring, restricting access to Labor Courts, and weakening collective bargaining. Also noteworthy was the Outsourcing Law (Law No. 13,429/2017), which allowed unrestricted outsourcing, including core activities, thereby weakening employment relationships and workers’ social protection. These counter-reforms were justified by the government as stimuli to modernization and job creation and relaxed rights historically guaranteed to workers³¹.

The justification for these counter-reforms is often based on an alarmist discourse that invokes a supposed imminent “collapse” of Brazil unless structural changes are implemented. This discourse uses terms such as “relax” and “modernize” to legitimize measures that, in practice, dismantle social and labor rights won over decades. In health, this is reflected in the acceleration of non-classical privatization processes that transfer public management to private organizations, in underfunding, and in the freezing of financial resources, as imposed by Constitutional Amendment No. 95. These actions are sustained by the so-called “political culture of crisis” and create a situation in which the weakened and dismantled essential public services are presented as inevitable, consolidating inequalities and compromising the universal right to health³⁰^,³¹.

Still under the Temer administration, changes in the Ministries of Health and Education brought significant setbacks, such as the repeal of the PMM’s structuring measures. During Jair Bolsonaro’s government, the interruption of international cooperation with PAHO and Cuba cut the program’s number of doctors in half. In response, the Doctors for Brazil Program (PMPB) was instituted; although it criticized the PMM, it retained part of its guidelines but excluded international recruitment and authorization for foreign doctors without registration in Brazil. However, the growing demand for doctors was exacerbated by the COVID-19 pandemic and forced the government to use the PMM structure³².

In 2019, Brazil had 15 million people living in extreme poverty, 55 million in poverty, 34 million without access to treated water, and more than 100 million without sewage collection. Despite this critical outlook, the Federal Government prioritized measures that escalated conflicts and marginalized vulnerable populations. The exclusion of the Sustainable Development Goals (SDGs) from the 2020-2023 Pluriannual Plan and the extinction of the National SDG Commission exemplify this setback³³.

The COVID-19 pandemic exacerbated the political, social, and economic crises, exposing disparities and the weaknesses of the health system. Federal management was marked by a lack of coordination, attacks on health workers, delegitimization of science, and negligence in confronting the crisis. To mitigate the impacts, the strategic initiative “Brazil Counts on Me” was created to train health professionals and establish a national registry. However, infrastructure difficulties, work overload, and failures in coordination among government levels compromised its effectiveness³⁴^-³⁸.

Beyond HWF management, other challenges included the availability of tests, vaccines, and hospital beds. Countries that rapidly implemented social containment measures and widespread testing achieved better results in combating the pandemic⁴². However, in Brazil, the delayed response contributed to high rates of infection and deaths, including among health professionals, with more than 4,500 deaths by 2022³⁹. During the crisis, the government authorized the early graduation of health students, a controversial decision criticized for the possible risks of exposure to the virus and inadequate preparation⁴⁰^-⁴³. Another significant setback was extinguishing the MNNP-SUS.

According to PAHO, in this Brazilian social and political context, the major challenges for HRH policy were concentrated in: investing in HRH allocation and distribution; influencing trends toward concentration of the HWF in urban areas and at higher complexity levels, as well as labor fragmentation; and establishing mechanisms for democratizing the supply of health education, ensuring quality, advancing interprofessional training, and valuing training in primary care, emphasizing family health⁴⁴.

The resumption of politics (2023-2024): Democracy, labor, and health education for development

After a closely contested election in 2022, Luiz Inácio Lula da Silva returned to the Presidency in 2023, defeating the then-President Jair Bolsonaro. Even with the prospect of resuming the ideals of Public Health policies, the government faced, at the very start of its term, an attempted coup with the attack on the Planalto Palace, while also addressing social polarization and the difficulty of lacking a majority in the National Congress.

Despite these challenges, the first year of the term was marked by important structural and symbolic changes. For the first time in history, a woman was appointed Minister of Health-Nísia Trindade Lima-representing a significant milestone for gender equity in leadership positions in the public sector, as well as a return to science as a guiding principle in the Ministry, given her stature as a renowned scientist. In addition, strategic positions in the Ministry of Health were filled by leaders with extensive trajectories within the SUS⁴⁵.

Among the new government’s main actions was the resumption of public policies that had been discontinued or weakened in recent years. Significant efforts were directed toward strengthening labor management and health education, with a focus on valuing professionals, technical qualifications, and interprofessional integration⁴⁶.

At the beginning of the term, emergency government initiatives related to public health were implemented, as if it were “putting out fires”. These actions included care and policies directed toward the Yanomami population; the resumption of the National Immunization Program; the creation of the National Program for Reducing Waiting Lists for Elective Surgeries, Complementary Examinations, and Specialized Visits; and the revival of the Popular Pharmacy Program⁴⁷.

In March 2023, the government relaunched the PMM to increase the presence of health professionals in underserved areas and remote regions of the country. By the end of the year, the program had reached a record number of enrollments, with 28,000 doctors deployed, benefiting more than 96 million Brazilians in primary care⁴⁷^,⁴⁸.

Another initiative was the launch of the New Growth Acceleration Program (PAC Saúde), which provides for investments of 31 billion through 2026 for the construction and modernization of health units throughout the country. Within the Health Economic-Industrial Complex, investments of 4.2 billion were announced to expand domestic production of medicines and essential inputs, strengthening the health industry in Brazil⁴⁹.

Also noteworthy is the National Strategy for the Training of Health Experts, launched to expand the training of specialized professionals in strategic areas, aiming to fill regional gaps and strengthen primary and specialized care in the SUS. At the same time, the National Program for Gender Equity, Racial Equity, and the Valuation of Women Workers in the SUS seeks to promote fair and equal working conditions, addressing structural inequality and ensuring the valuation and recognition of women and racialized populations, who make up the majority of the Brazilian HWF⁴⁷.

The National Health Plan (2024-2027) establishes guidelines aimed at strengthening Primary Care by expanding the coverage of the Family Health and Oral Health Strategies, ensuring universal access, comprehensive care, and the reduction of social, regional, racial, and gender inequalities. It also seeks to expand access to Specialized Care, control preventable diseases, promote scientific and technological development, broaden access to medicines and pharmaceutical services, strengthen the supply of health actions and environmental sanitation with a focus on Indigenous peoples, and improve the strategic management of the SUS by investing in innovation, digital health, labor, and health education. These guidelines represent a landmark for the reconstruction and consolidation of the SUS, with a focus on equity, inclusion, and the sustainability of the system⁵⁰.

At the same time, the Fourth National Conference on Labor Management and Health Education was held, under the theme “Democracy, Labor, and Health Education for Development: The People Who Make SUS Happen”. The conference’s final report is crucial for the debate and construction of guidelines aimed at qualifying and valuing the HWF in the SUS. Among its main themes were the implementation of policies to retain professionals in vulnerable areas, create career and salary plans, strengthen interprofessional training, and value primary care⁵¹.

Final reflections

The HWF is facing a global crisis, and over recent decades, Brazil has witnessed the implementation of several macropolitical strategies to address this challenge. The national landscape concerning the agenda of labor management and health education, analyzed in light of different moments over the last four decades, reflects a dynamic marked by alternating emphases on politics and anti-politics.

In the field of public policy, it is crucial to understand that government actions in response to social and collective demands shape the context in which the HWF operates. Public policies are not isolated entities; rather, they are reflections of the social environment, involving complex negotiations of values, ideologies, and competing interests.

Given this complex interaction among politics, anti-politics, and national challenges related to the HWF, the approaches adopted should consider not only immediate demands but also the long-term sustainability and strengthening of the health system. Balancing individual and collective interests, combined with a deep understanding of political dynamics, is essential to ensure a robust workforce that can address emerging challenges in the global health landscape.

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» https://www.coren-rj.org.br/mais-de-4-500-profissionais-de-saude-morreram-por-covid-19-no-brasil
⁴⁰ Brasil. Ministério da Educação (MEC). Portaria nº 356, de 20 de março de 2020. Dispõe sobre a atuação dos alunos dos cursos da área de saúde no combate à pandemia do COVID-19 (coronavírus). Diário Oficial da União 2020; 20 mar.
⁴¹ Brasil. Ministério da Educação (MEC). Portaria nº 383, de 9 de abril de 2020. Dispõe sobre a antecipação da colação de grau para os alunos dos cursos de Medicina, Enfermagem, Farmácia e Fisioterapia, como ação de combate à pandemia do novo coronavírus - Covid-19. Diário Oficial da União 2020; 13 abr.
⁴² Hayter M, Jackson D. Pre-registration undergraduate nurses and the COVID-19 pandemic: students or workers? J Clin Nurs 2020; 29(17-18):3115-3116.
⁴³ Almeida ML, Santos MJ. Negociação coletiva no setor público e retomada da MNNP. Rev Cienc Trab 2023; 24:1-11.
⁴⁴ Organização Pan-Americana da Saúde (OPAS). Ministério da Saúde (MS). Fortalecimento da gestão do trabalho e da educação na saúde para o SUS. Washington, D.C.: OPAS; 2020.
⁴⁵ Machado CV. Democracia, cidadania e saúde no Brasil: desafios para o fortalecimento do SUS. Cien Saude Colet 2024; 29(7):e02192024.
⁴⁶ Brasil. Ministério da Saúde (MS). Plano Nacional de Saúde 2024-2027. Brasília: MS; 2024.
⁴⁷ Giovanella L, Bousquat AEM, Mendonça MHM, Facchini LA. 100 dias do governo Lula na saúde. Cad Adenauer 2023; 1:111-131.
⁴⁸ Brasil. Ministério da Saúde (MS). Balanço 2024. Brasília: MS; 2024.
⁴⁹ Brasil. Ministério da Saúde (MS). Novo PAC: 96% das propostas de investimento em serviços de saúde foram aprovadas. Brasília: MS; 2024.
⁵⁰ Brasil. Ministério da Saúde (MS). Plano Nacional de Saúde - PNS 2024-2027. Brasília: MS; 2024.
⁵¹ Brasil. Ministério da Saúde (MS). Secretaria de Gestão do Trabalho e da Educação na Saúde. Relatório final da 4ª Conferência Nacional de Gestão do Trabalho e Educação na Saúde. Brasília: MS; 2024.

Data availability statement
The data sources adopted in the research are indicated in the article’s body.

Chief editors:
Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva, Vania de Matos Fonseca

Data availability

The data sources adopted in the research are indicated in the article’s body.

Publication Dates

Publication in this collection
24 July 2026
Date of issue
June 2026

History

Received
31 Jan 2025
Accepted
12 Mar 2026
Published
14 Mar 2026

Este é um artigo publicado em acesso aberto sob uma licença Creative Commons

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[30] ³⁰ Silva TMR, Sá ACGN. Desafios da cobertura vacinal no Brasil: fake news e desigualdades. LEIASS; 2023.

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[32] ³² Pinto HA, Oliveira FP, Soares R. Panorama da implementação do Programa Mais Médicos até 2021. Rev Baiana Saude Publica 2022; 46(1):32-53.

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[34] ³⁴ Ortega F, Orsini M. Governing COVID-19 without government in Brazil. Glob Public Health 2020; 15(9):1257-1277.

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[37] ³⁷ Ribeiro AP, Oliveira GL, Silva LS, Souza ER. Saúde e segurança de profissionais de saúde no contexto da COVID-19. Rev Bras Saude Ocup 2020; 45:e25.

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[39] ³⁹ Conselho Regional de Enfermagem do Rio de Janeiro. Mais de 4.500 profissionais de saúde morreram por COVID-19 no Brasil [Internet]. 2023 [acessado 2025 jan 31]. Disponível em: https://www.coren-rj.org.br/mais-de-4-500-profissionais-de-saude-morreram-por-covid-19-no-brasil/.
» https://www.coren-rj.org.br/mais-de-4-500-profissionais-de-saude-morreram-por-covid-19-no-brasil

[40] ⁴⁰ Brasil. Ministério da Educação (MEC). Portaria nº 356, de 20 de março de 2020. Dispõe sobre a atuação dos alunos dos cursos da área de saúde no combate à pandemia do COVID-19 (coronavírus). Diário Oficial da União 2020; 20 mar.

[41] ⁴¹ Brasil. Ministério da Educação (MEC). Portaria nº 383, de 9 de abril de 2020. Dispõe sobre a antecipação da colação de grau para os alunos dos cursos de Medicina, Enfermagem, Farmácia e Fisioterapia, como ação de combate à pandemia do novo coronavírus - Covid-19. Diário Oficial da União 2020; 13 abr.

[42] ⁴² Hayter M, Jackson D. Pre-registration undergraduate nurses and the COVID-19 pandemic: students or workers? J Clin Nurs 2020; 29(17-18):3115-3116.

[43] ⁴³ Almeida ML, Santos MJ. Negociação coletiva no setor público e retomada da MNNP. Rev Cienc Trab 2023; 24:1-11.

[44] ⁴⁴ Organização Pan-Americana da Saúde (OPAS). Ministério da Saúde (MS). Fortalecimento da gestão do trabalho e da educação na saúde para o SUS. Washington, D.C.: OPAS; 2020.

[45] ⁴⁵ Machado CV. Democracia, cidadania e saúde no Brasil: desafios para o fortalecimento do SUS. Cien Saude Colet 2024; 29(7):e02192024.

[46] ⁴⁶ Brasil. Ministério da Saúde (MS). Plano Nacional de Saúde 2024-2027. Brasília: MS; 2024.

[47] ⁴⁷ Giovanella L, Bousquat AEM, Mendonça MHM, Facchini LA. 100 dias do governo Lula na saúde. Cad Adenauer 2023; 1:111-131.

[48] ⁴⁸ Brasil. Ministério da Saúde (MS). Balanço 2024. Brasília: MS; 2024.

[49] ⁴⁹ Brasil. Ministério da Saúde (MS). Novo PAC: 96% das propostas de investimento em serviços de saúde foram aprovadas. Brasília: MS; 2024.

[50] ⁵⁰ Brasil. Ministério da Saúde (MS). Plano Nacional de Saúde - PNS 2024-2027. Brasília: MS; 2024.

[51] ⁵¹ Brasil. Ministério da Saúde (MS). Secretaria de Gestão do Trabalho e da Educação na Saúde. Relatório final da 4ª Conferência Nacional de Gestão do Trabalho e Educação na Saúde. Brasília: MS; 2024.

Year	Initiatives
Pre-SUS
1986	Eighth National Health Conference: A landmark event that consolidated the foundations for the creation of the Brazilian Unified Health System (SUS), recognizing health as a right and a duty of the State and proposing a decentralized, comprehensive, and participatory model for health care.
1986	First National Conference on Human Resources for Health (CNRHS): The event addressed issues such as care, humanization, the working conditions of health professionals, and the quality of care provided to the population.
1988	Federal Constitution: Promulgation of the 1988 Brazilian Constitution, also known as the Citizen Constitution.
1990	Law No. 8,080/1990: Article 27 establishes objectives for the education, training, and valuing of human resources in the Brazilian Unified Health System (SUS).
Anti-politics period
1998	Basic Operational Standard for Human Resources for the SUS (NOB/RH-SUS) - First version: Definition of principles and guidelines for workforce management in the SUS.
2000	Fiscal Responsibility Law: This law establishes, at the national level, parameters for public spending by each federative entity.
Politics period
2003	Reestablishment of the National Permanent Negotiation Forum of the Brazilian Unified Health System (MNNP-SUS): The forum was reinstated and resumed its activities, adopting as priorities a set of challenges such as labor regulation; reducing insecure employment; career, position, and salary plans; worker health; and the establishment of state and municipal negotiation forums. National Program for Reducing Insecure Employment in the SUS (DesprecarizaSUS): A federal government action strategy created with the objective of seeking solutions to precarious work arrangements across the three levels of government. National Humanization Program (HumanizaSUS): It seeks to put the principles of the Brazilian Unified Health System into practice in health services, producing changes in ways of caring and managing. It aims to stimulate communication among managers, workers, and users in order to build collective processes for confronting power relations and labor relations.
2004	National Policy for Continuing Education in Health (PNEPS): It adopts continuing education in health as a pedagogical, political, and theoretical-methodological strategy for transforming professional practices and work organization in favor of improving care and assistance to the population. Experiences and Internships in the Reality of the Brazilian Unified Health System (VER-SUS): A proposal to provide undergraduate students with a period of multiprofessional immersion in a municipal or state health system. AprenderSUS: It uses comprehensiveness as the guiding axis for changes in the education of health professionals in undergraduate health programs.
2005	National Program for the Reorientation of Professional Education in Health (Pro-Saude): It was launched to improve the initial implementation initiative of the National Curricular Guidelines for Health Programs and to broaden coverage to other health professions that are part of the Family Health Strategy (ESF). Multiprofessional Residency in Health (RMS): Regulation of the RMS modality through Interministerial Ordinance MEC/MS No. 2,117 of November 3, 2005. Years later (2009), the National Commission for Multiprofessional Residency in Health was created through Interministerial Ordinance MEC/MS No. 1,077 of November 12, 2009, which defines the modality as lato sensu postgraduate education, with a workload of 60 hours per week and a minimum duration of two years.
2006	Program for the Qualification and Structuring of Workforce Management and Health Education in the SUS (ProgeSUS): It was created to structure, qualify, and equip health departments with management tools for the organization and professionalization of workforce management in the Brazilian Unified Health System.
2007	Brazil Telehealth Networks: A program established to strengthen and improve the quality of primary care in the Brazilian Unified Health System by integrating teaching and service through information and communication tools and technologies.
2008	Program for Education through Work for Health (PET-Saude): It was established as one of the strategies of Pro-Saude, and was instituted by Interministerial Ordinance MS/MEC No. 1,802/2008, to expand, promote, coordinate, and support educational actions and activities aimed at changes in undergraduate health education and teaching-service-community integration linked to continuing education.
2009	Program for the Training of Mid-Level Health Professionals (PROFAPS): It was designed to qualify and/or certify workers through professional education courses for the Brazilian Unified Health System.
2010	National Program to Support the Training of Specialist Doctors in Strategic Areas (Pro-Residencia): It provides for the expansion of medical residency scholarships in specialties and regions prioritized by the Brazilian Unified Health System. It was later extended to multiprofessional residencies. Open University of the SUS System (UNA-SUS): Training and continuing education for professionals working in the Brazilian Unified Health System, through a collaborative network formed by several higher education institutions that offer free distance-learning courses.
2011	Program for the Valuing of Primary Care Professionals (PROVAB): It was created to encourage and value health professionals working in multiprofessional teams within Primary Health Care (PHC) and the Family Health Strategy (ESF), and place them in locations with greater shortages of access to health care providers.
2013	More Doctors Program (PMM): It was instituted by the Federal Government to improve care for users of the Brazilian Unified Health System. In addition to bringing more doctors to regions where these professionals are scarce or absent, the program also provides more investment for the construction, renovation, and expansion of PHC Units, as well as new undergraduate and medical residency vacancies to improve the training of these professionals.
2015	Organizational Contracts for Public Action in Teaching-Health (COAPES): It was intended to qualify teaching-service integration and continuing education in the territories by involving agreements between educational institutions and municipal, state, and federal managers of the Brazilian Unified Health System. It presupposes the contractualization of agreements established between managers who offer their network as a field of practice and educational institutions with health programs interested in placing their students in the service network.
Return of anti-politics
2016	Constitutional Amendment Establishing a Public Spending Cap (EC No. 95): It froze public spending, including investments in health and education, for 20 years, adjusted only for inflation. It restricted resources for the SUS, directly affecting the workforce and the capacity to expand health services.
2017	Ordinance No. 3,588/2017: It reformulated the National Primary Care Policy (PNAB), making the Family Health Strategy (ESF) less mandatory and allowing the creation of new modalities of Primary Care teams. Launch of the document entitled “Brazil Health Coalition: An agenda to transform the health system”: An initiative by the private sector and business organizations, the document proposed reforms in Brazilian health management, prioritizing efficiency and financial sustainability. The movement reinforced health privatization and encouraged reducing the role of the State in the regulation and financing of the SUS.
2019	Extinction of the National Permanent Negotiation Forum of the SUS: This privileged space for the defense of workers and of the SUS had existed since 1993. It was abolished by the Bolsonaro government. In addition, the government eliminated the National SDG Commission and excluded these objectives from the 2020-2023 Multi-Year Plan. Doctors for Brazil Program (PMPB): Instituted by Law No. 13,958, of December 18, 2019. Despite strong rhetoric criticizing the achievements of previous governments, the PMPB reproduced the provision axis of the PMM, but without international recruitment and without authorization for doctors trained abroad and without Brazilian registration to practice in the country.
2020	Strategic Action “Brazil Counts on Me”: It aimed at the training and registration of health workers to streamline human resources in health services within the SUS. It was complemented by Ordinance No. 374/2020 of the Ministry of Education. Measures to address the public health emergency - COVID-19: Ordinance No. 374/2020 of the Ministry of Education was published, authorizing federal higher education institutions to anticipate graduation for students in the final stage of their programs, provided that they had completed 75% of the workload scheduled for the medical internship or supervised curricular internship.
Resumption of politics
2023	Relaunch of the More Doctors Program: Based on MS/MEC Ordinance No. 604 of May 16, 2023, the program was resumed with changes in remuneration, incentives for retaining professionals, and expanded access for Brazilian doctors trained abroad. The new More Doctors Program seeks to reverse the shortage of professionals in Primary Care, prioritizing practice in remote and underserved areas. National Strategy for the Training of Specialists for Health: Aimed at expanding the training of specialists in the country, this strategy seeks to balance the distribution of doctors and other health professionals, strengthening priority areas of the SUS, such as Family and Community Medicine, urgent and emergency care, and mental health. It was instituted by Provisional Measure No. 1,165 of March 20, 2023. National Program for Gender Equity, Racial Equity, and the Valuing of Women Workers in the Brazilian Unified Health System: Focused on promoting gender and racial equity within the SUS, it seeks to reduce wage inequalities, expand the presence of women and Black people in management positions, and ensure decent working conditions, especially for health professionals in vulnerable contexts. New Growth Acceleration Program (PAC) Health: GM/MS Ordinance No. 1,517 of October 9, 2023, instituted the new PAC Health. It includes investments to modernize hospital infrastructure, expand the Primary Care network, and improve the working conditions of health professionals. It proposes financing for the construction of new Basic Health Units and university hospitals.
2024	National Health Plan (2024-2027): Resolution No. 741 of February 22, 2024, a strategic document for the SUS in the coming years, focuses on reorganizing the care network, qualifying the workforce, and expanding access to health care. It prioritizes the expansion of the Family Health Strategy and the valuing of professionals. Fourth National Conference on Human Resources in Health: With discussion of workforce management and health education policies, the conference addressed challenges such as insecure employment, the impact of Constitutional Amendment No. 95, and strategies to strengthen the SUS through professional qualification and worker valuing.