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Ciência & Saúde Coletiva

Print version ISSN 1413-8123On-line version ISSN 1678-4561

Ciênc. saúde coletiva vol.20 no.10 Rio de Janeiro Oct. 2015 


Social inequality, health policies and the training of physicians, nurses and dentists in Brazil and in Portugal

Isabel Maria Rodrigues Craveiro 1  

Virginia Alonso Hortale 2  

Ana Paula Cavalcante de Oliveira 1  

Gilles Dussault 1  

1Global Health and Tropical Medicine, Unidade de Saúde Pública Internacional e Bioestatística, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa. R. Junqueira 100, Campolide. 1349-009 Lisboa Portugal.

2Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz


This study analyzes the production of scientific knowledge on Health Inequalities (HI) and its use in policies of education of dentists, nurses and physicians in Brazil and Portugal. Documents published between January 2000 and December 2001, in Portuguese, French, English and Spanish, were identified by means of a combination of a manual and intentional electronic database survey of the grey literature. Fifty-three documents were selected from a total of 1,652. The findings revealed that there is still little knowledge available to enable an assessment of policies for human resource training in healthcare in general and for those related to physicians, nurses and dentists in particular. In Brazil, few studies have thus far been made to understand how such training can contribute towards reducing these inequalities and, in the case of Portugal, no studies were found that established a direct relationship between human resource training and the future role that these could play in combating inequality. Despite a vast increase in scientific production, many lacunae still exist in this field. Knowledge production and its relationship with decision-making still seem to be separate processes in these two countries.

Key words Evidence-based policies; Social inequalities in health; Training; Human resources in health (HRH); Health policy


O estudo analisa a produção do conhecimento científico sobre desigualdades sociais em saúde e discute sua relação com as políticas de formação de dentistas, enfermeiros e médicos no Brasil e em Portugal. Foram identificados documentos publicados em Português, Francês, Inglês e Espanhol, entre janeiro de 2000 e dezembro de 2012, por meio da combinação de levantamento em bases de dados eletrônicas, manual e intencional da literatura cinzenta. Foram selecionados 53 documentos de um total de 1652. Os resultados mostram escassez de conhecimento para permitir a avaliação das políticas de formação de recursos humanos em saúde em geral e aquelas relativas a médicos, enfermeiros e dentistas, em particular. No Brasil, ainda são poucos os estudos que procuram entender como essa formação pode contribuir para a diminuição das desigualdades e, para Portugal, não encontramos estudos que estabeleçam uma relação direta entre a formação de recursos humanos e um eventual papel que esses poderão desempenhar no combate às desigualdades. Apesar de um grande aumento na produção científica, muitas lacunas persistem nesse campo. A produção de conhecimento e sua relação com a tomada de decisão parecem ainda ser processos separados nos dois países.

Palavras-chave Políticas baseadas em evidência; Desigualdades sociais em saúde; Formação; Recursos humanos em saúde (RHS); Política de saúde


Despite improvements in health determinants, social inequalities are still a major problem in public health13. In many European countries, including Portugal, several health indicators, such as life expectancy and infant mortality, have shown improvements during recent decades; however, considerable challenges still exist in relation to geographic variations between social groups and minorities and the care required for an aging population4,5. In the case of Brazil, although improvements have been seen during recent years, regional, geographic and social inequalities remain unchanged for mortality and morbidity rates6. In order to respond to these, the health systems need to make improvements in terms of effectiveness, efficiency and equity7.

In order to achieve equity of access and the use of health services, the health systems should be organized in such a way as to reduce barriers of access to the population as a whole8, and Human Resources in Health (HRH) are seen as one of the essential pillars to attain this objective9,10.

There has been an increase in scientific publications in the area of social inequality, which brings to the fore the question of how they are used to form health policies and, in particular, for HRH training, employability and management, bearing in mind the contribution this has made to help strengthen the health system and to provide equal access to its services11. Ultimately, this production can be used to meet the objectives outlined in the Universal Health Coverage adopted by member states of the United Nations in 201212 and supported by its agencies, principally by the World Health Organization (WHO)13.

Several authors note the need to undertake studies into the evolution of knowledge production, as well as ways to use this and the impact that this knowledge will have when integrated into policies14,15. They also recognize the relevance of integrating knowledge production related to social inequalities and their different (social, economic, cultural) determinants in health policy investigations and formulation agendas.

Thus, it is important to understand if advances have been made in using knowledge produced for the definition of health policies16, bearing in mind the growing need for decisions made by management, clinicians and policy makers to be based on solid scientific knowledge. We acknowledge that the process of elaborating health policies takes into account research findings17,18, in spite of differences existing between researchers and decision-makers15, in terms of the theoretical reference frameworks used to approach these issues. In addition, there is an inherent complexity involved in the interaction between research and policy-making, due to the nature of scientific information, very often plentiful, which is diversified and inaccessible to policy-makers19.

It is recognized that there is a lack of comparative studies used to review literature about how knowledge production is applied15. Understanding how the formulation of health policies can benefit from comparisons made between countries, shows the relevance of conducting transnational studies about how research findings are applied.

In order to make an analysis of issues that are of interest both to Portugal and Brazil, in view of their cultural similarities and language, we used a conceptual framework that made it easier to analyze the findings obtained in both countries. This article presents the findings of the first stage of a study aimed at analyzing the barriers and the facilitators for the use of knowledge produced, according to researchers and policy makers, who are the potential users of such knowledge. Naturally, further studies will be needed to identify factors that maintain barriers to disseminating knowledge about social inequalities and the potential this has to be used to formulate HRH training policies, which aim to reduce same.

Thus, the aim of this study is to analyze the production of scientific knowledge about social inequalities in health and to discuss its relationship with training policies for physicians, nurses and dentists in Brazil and Portugal.


Between October 2012 and January 2013, in accordance with Torraco20, we undertook an integrative survey of the literature on social inequalities in healthcare and the training of physicians, nurses and dentists for the period between January 2000 and December 2012. This was done using open access electronic data bases from Pubmed/The National Library of Medicine/ Washington; the Pan-American Health Organization; the Virtual Health Library (BVS) via Bireme (consisting of the Latin American and Caribbean Literature - LILACS, Wholis, the WHO library database, The Cochrane Library, among others); the CAPES thesis database; the Network of HRH observatories in Brazil; the Brazilian Ministry of Health; the Portuguese Directorate-General of Health (DGS); the Health Portal of Portugal and Google Scholar - and other sources of restricted access (e.g. unpublished books, documents).

We used key words such as "human resources," "health," "health professionals," "physicians," "nurses," "dentists," "training policy," "intervention," "inequality" and "iniquities," and we researched these in combinations, separately, with an alteration to the ending of a word and in other languages, according to the specificity of each database. To analyze the documents, we divided the key words into two sections: scientific production in social inequalities in health and HRH trainingand health training policies and interventions.

For the first section, we sub-divided the documents as follows:

    –. Context – documents related to institutional issues (of the health system) and in the context of producing policies for graduate, post-graduate and ongoing training for professionals who are studying, and documents that explain the social context of producing knowledge and HRH training policies;

    –. Empirical studies – correspond to investigations that have been conducted with a presentation of their research findings. These include an extension of the problem, possible interventions and an assessment of training policies for professionals who are undertaking studies;

    –. Policies: documents published in the Official Government Gazette and reports identified as publications that support policies.

For the second section, we subdivided documents according to their type of approach to HRH training:

  1. – documents that only mention or show the problem of social inequality in health;

  2. – documents that mention or present and discuss the problem (adjusted, for example, for the context of the country, region, etc.);

  3. – documents that present solutions or strategies or interventions in terms of training;

  4. – documents that access HRH training policies;

When analyzing these documents, we considered four types of inequalities based on Therborn21:

  • Economic – including the distribution of income and material resources;

  • Social or living conditions – including gender, race, education, geographic location, vulnerable populations (migrants, immigrants and indigenous peoples);

  • Institutional or the organization of health systems – including inequality in the regional distribution of HRH, the level of healthcare and access to and use of healthcare services;

  • In comprehensive health – whenever authors present this in very broad terms, i.e., lacking sufficient information to enable a classification to be made, or when all types of inequalities mentioned above were included.

The inclusion criterion were: articles published between January 2000 and December 2012, in Portuguese, English, French and Spanish; on physicians, nurses and dentists; empirical and/or conceptual/theoretical works using the terms ‘inequality/social health determinants," or research where interventions in the area of the training of physicians, nurses and/or dentists, or health professionals in general, were covered by these policies. In view of the systemization of these studies we used the following concepts:

  • Social inequalities in health – these are the systematic differences in the health situation of different population groups – social inequalities in health conditions and in access to and use of healthcare services illustrate differential opportunities resulting from a person's social position and which characterize situations of social injustice which represent iniquity8.

  • Iniquities – this refers to inequalities in health which, as well as being systematic and relevant, are avoidable, unjust and unnecessary22; these include inequalities in living conditions and income distribution23.

  • Social determinants of health (SDH) – are the social condition in which people live and work or "the social characteristics within which their lives are lived"24.

In summary, so many social inequalities in health such as SDH represent inequalities in social groups who have more or less advantages, which place the former at a disadvantage. Equity cannot be assessed without the inclusion of this element of comparison between groups who receive greater and fewer benefits25. Social inequalities in health vary between different countries, in accordance with the way their health systems are organized. In this respect, the Commission for Social Determinants of Health (CSDH)26 considers that health systems represent one of the determinants of social inequality in health conditions, and play a relevant role in reducing these; although Travassos and Castro8 state that modifying the characteristics of the health system directly changes the social inequalities involved in access and use of such services, but are incapable in themselves of changing the social inequalities in health conditions that exist between different social groups.

"Health policy" refers to decisions, plans and actions employed to achieve a specific objective in health within a certain society and define a vision for the future, which helps establish short and medium-term goals, establish priorities and the roles attributed to different actors27. These include laws, regulations, decree-laws, but also technical documents in support of policies19 and programs.

This may be understood as the formal side of health policy – the legal (the Federal Constitution, laws and executive actions), the institutional (Ministries, Secretariats and the Legislative), official statements (national health policy) and the actions of a group of individuals within society whose main task is to prepare laws and execute policies28.

This study does not consider cases of "informal policies," namely citizen participation; and we understand the term "production of knowledge" as "the scientific production of knowledge"29.


Of the total of 1.652 documents found in the databases that we researched, fifty-three were selected. Of these, the majority (53%) are "contextual," followed by "empirical" (21%) and "policy" (26%) documents.

As regards the type of document selected, in the case of Brazil, most of these (25%) are articles, followed by Master's dissertations and doctoral thesis and policy documents. Documents related to legislation and technical reports supporting policies were found in equal numbers – 19%. In the case of Portugal, most of the documents relate to policy, that is, interventions by the Ministry of Health, the National Health Plan (PNS) and legislation (41%), followed by investigative reports (35%).

The institutions promoting most of the documents selected were universities (46%), followed by national organs (43%) and a minority was international organizations (11%). This distribution varies in both countries – in Brazil, most documents were connected to universities while in Portugal the great majority were promoted by national organs (Table 1).

Table 1 Characteristics of the institution that promoted the study, type of document, according to country studied. 

Promoting institution and type of document Brazil Portugal Overall total
Context Empirical Policy Total Context Empirical Policy Total
Institution that promoted the study/legislation
National organization 5 7 12 3 1 7 11 23
International organization 2 2 3 1 4 6
University 13 9 22 2 2 24
Type of document
Article 7 2 9 1 1 10
Master's dissertation 4 3 7 7
Mnistry of Health intervention 2 2 2
Legislation 3 3 3 3 6
Book 1 1 1 1 2
National Health Plan 2 2 2
Research report 1 1 4 2 6 7
Technical policy support report 4 4 4
Institutional technical report 3 3 2 2 5
Doctoral thesis 3 4 7 7
Course conclusion paper specialization 1 1 1
Total 20 9 7 36 8 2 7 17 53

Documents in Brazil focus mainly on social inequalities in health in broad terms (59%), while most (71%) in Portugal refer to inequalities in social conditions. The groups of documents selected, related to professionals, to the type of inequality, the classification of the document and the type of training approach used, are shown in Chart 1.

Chart 1 Findings of the survey related to professional groups, type of inequality, classification of document and type of approach to training for health professionals. 

Characteristics Reference Professional Type of inequality Classification of documents Type of approach for training health professionals*
Knowledge produced Cruz KT. 200430 physicians nurses Social/living conditions Context D
Santana JP, Christófaro MAC., 200131 Social/living conditions (education) Context C
Baganha MI et al. 200232 physicians and nurses Economic inequalities Context B
Rigoli F, Dussault G. 200333 general Comprehensive health inequalities Context C
Negri B. 200234 physicians and nurses Comprehensive health inequalities Context C
Deluiz N. 200135 general Comprehensive health inequalities Context A
Fonseca CD et al. 200236 physicians and nurses Comprehensive health inequalities Context D
Pierantoni CR. 200037 all Institutional/organization of health systems Context A
Gijón-Sánchez M et al. 201038 general Social/living conditions (migrants) Context C
Ceccim RB, Pinto LF. 200739 all Social/living conditions Context B
International Organization for Migration (IOM), Gijón-Sánchez, MT. 200640 general Social/living conditions (migrants) Context B
International Organization for Migration (IOM). 200941 general Social/living conditions (migrants) Context C
Portugal R et al. 200742 general Social/living conditions (migrants) Context C
Fernandes A, Pereira M (eds) Instituto Nacional de Saúde Doutor Ricardo Jorge. 200943 general Social/living conditions (migrants) Context A
WHO. 201144 general Social/living conditions (migrants) Context A
Modesto AA. 201045 dentists Comprehensive health inequalities Context B
Borde E et al. 201246 general Comprehensive health inequalities Context A
Canesqui AM. 201047 all Comprehensive health inequalities Context A
Casotti E. 200948 dentists Comprehensive health inequalities Context B
Conceição C. et al. 200149 all Comprehensive health inequalities Context B
Garcia ACP. 201050 general Comprehensive health inequalities Context D
Ferreira MAL, Moura AAG. 200651 general Comprehensive health inequalities Context B
Almeida DCS. 200852 all Comprehensive health inequalities Context B
Feuerwerker LCM. 200153 physicians Institutional/organization of health systems Context A
Petta HL. 201154 physicians Institutional/organization of health systems Context D
Knowledge produced Haddad AE et al. 201055 all Institutional/organization of health systems Context B
Vieira ALS, Amâncio Filho A. 200656 all Institutional/organization of health systems Context B
Pires-Alves F et al. 200857 all Institutional/organization of health systems Context D
Ministry of Health – Directorate - General of Health - Portugal 200558 general Social/living conditions (gender) Empirical study A
Lampert JB. 200259 physicians Institutional/organization of health systems Empírical study B
Aguirre MBF. 200860 general Comprehensive health inequalities Empirical study C
Armani TB. 200661 all Comprehensive health inequalities Empirical study B
Miyagima CH. 200962 general Comprehensive health inequalities Empirical study A
Marin MJS et al. 201063 all Comprehensive health inequalities Empirical study B
Dias HS. 201164 dentists Comprehensive health inequalities Empirical study B
Santos R. 200765 general Comprehensive health inequalities Empirical study C
WHO. 201066 nurses Comprehensive health inequalities Empirical study A
Zilbovicius C. 200767 dentists Comprehensive health inequalities Empirical study B
Martins RJ et al. 200968 dentists Institutional/organization of health systems Empirical study B
Policy documents Ministry of Health – National Health Plan 2004 – 201069 all Comprehensive health inequalities Policy --
National Health Plan PNS – A Health Pact for Brazil. 200470 all Comprehensive health inequalities Policy --
Presidency of the Council of Ministers. II National Plan for Equality. 2003-2006. 200371 general Social/living conditions (gender) Policy --
Presidency of the Council of Ministers. II National Plan Against Domestic Violence (2003-2006). 200372 general Social/living conditions (gender) Policy --
National Policy for the Permanent Education of Health Workers at the Ministry of Health. (PNEP-MS). Brazil. 200473 general Comprehensive health inequalities Policy --
Presidency of the Council of Ministers. IV National Plan Against Domestic Violence. (2011-2013). 201074 general Social/living conditions (gender) Policy --
National Health Promotion Policy. Brazil, Ministry of Health. 200675 general Comprehensive health inequalities Policy --
Ministry of Health – National Health Plan 2012-201676 all Comprehensive health inequalities Policy --
Portuguese Ministry of Health. 201277 general Social/living conditions (gender) Policy --
Portuguese Ministry of Health. 200778 general Comprehensive health inequalities Policy --
National policy for the permanent education for the social control of the Unified physicians and nurses Comprehensive health inequalities Policy --
Health System – SUS. Ministry of Health, National Health Council – Brasília. 200679
National Council for Health Secretariats. Work & Education Management in Health. 201180 all Comprehensive health inequalities Policy --
Resolutions issued by the National Health Council, Ministry of Health. National Health Council. Brasília: Published by the Ministry of Health. 200781 all Comprehensive health inequalities Policy --
Final Report of the 14th National Health Conference: Everyone uses the SUS. SUS in Social Security – Public Policy, Patrimony of the Brazilian People. Ministry of Health. 201282 all Comprehensive health inequalities Policy

*type A documents – those which only mention or address the problem of social inequality in health; type B documents – those that mention or present and discuss the problem; type C documents – those that present solutions or strategies or interventions in terms of training; type D documents – those that assess HRH training policies.

1. Dimension of scientific production about social inequalities in health and HRH training

In view of the fact that the first National Health Plan (PNS) was implemented in Portugal in 2004, and that in 2006 Brazil created the Program of Qualification & Structuring for Health work Management and Education - PROGESUS, for the Unified Health System (SUS), we established two periods of analysis: 2000-2005 and 2006-2012.

We ascertained that out of thirty-nine documents found in the two countries, those that were relevant and published between 2000 and 2005 have a strong situation diagnosis component; are based only on a review of literature and documental analysis3034two of which35,36 do not describe the methodology used. Only one study assessed the setting up of the Human Resources Information & Management System in Health SIG-RHS37.

In the case of documents related to the period between 2006 and 2012, these also showed a predominance of theoretical studies or literature reviews3856, (one of which did not define the methodology used57). The tendency to conduct a situation diagnosis is maintained in the empirical studies for the first period58,59; and, documents related to the following years6068 do not show any implementation or assessment in the area of training policy.

Among the documents mentioned above, the most frequent focused on what is known as "inequality in comprehensive health." In most cases, the authors do not present a definition of the concept of inequality and when this does appear, the authors use the concept outlined by the WHO40,43,46, or a specific reference44, or do not even indicate a reference for the respective definition38,42. The way that health professionals are studied varies greatly, but most do this in general terms33,35,38,4044,46,50,51,58,60,62,65, while others deal with all professionals included in this review37,39,47,49,52,5557,61,63. We found eleven documents where the professional categories had been studied separately (physicians, nurses and dentists)30,31,45,46,53,54,59,64,6668 and a further three documents that approached problems involving physicians and nurses32,34,36.

There is a predominance of type A documents – those which only mention or address the problem of social inequality in health (ten); and B – documents that mention or present and discuss the problem (sixteen). Fewer documents relate to type C – documents that present solutions or strategies or interventions in terms of training (eight); and in D – documents that assess HRH training policies (five). With these findings, we could see that very little information has been produced on the subject, which contains an evaluative dimension on HRH training policies in general, as well as those related to the professionals being investigated.

2. Scientific production on the articulation between HRH training and social inequalities in health

Aspects related, either directly or indirectly, to HRH training are the main focus of thirty of the thirty-seven documents. The remaining documents focus on social inequalities in health and at the same time address several questions related to training.

When we analyzed the way inequality is treated in the thirty documents whose main focus is related to the training of health professionals, we identified the following five levels: residual inequality, with only one mention of the word "inequality" and unrelated to the present subject matter of training issues31,35,47,67; indirect inequality, in that the discussion about training of health professionals only indirectly involves inequality, without discussing its relationship with HRH training policies and interventions, or with SUS equity objectives SUS34,36,45,48,51,57,61,6365,68 and the contribution this has made towards tackling regional inequalities, or as part of understanding the context30,39,49,59, or even to register HRH training within the scope of the National Policy for Science, Technology & Innovation in Health – PNCTIS, which is also designed as "an instrument to reduce health inequality"; latent inequality (without integration in interventions) because inequalities are recognized as one of the greatest challenges in nursing, but which do not present any relationship with the question of training and its role, for example, in reinforcing the competencies of these professionals in dealing with vulnerable populations66; adjustment to inequality involving the challenges shown, either in terms of HRH training related to existing national and regional inequalities50, national social inequalities32, or problems of training specialist physicians and inequalities in regional distribution53,54, or in terms of HRH policies related to inequalities in the country37, or even the evolution of courses adapted to the National HRH Conferences and articulated with social movements in Brazil52; strategic inequality appears in documents where training is presented as a strategy to achieve equity33 or to reduce inequalities38; or even as a strategy to reduce inequalities in HRH, by distributing courses55,56.

The seven remaining documents4044,46,58 focus mainly on inequalities among migrant populations, and are heterogenic in the way they deal with questions of training. This makes us believe there is an indirect relationship between problems of inequality and the training of "health technicians," when emphasis is given to the importance of alerting them to these issues and that they could become "agents in the reduction of inequalities."

3. Policies and interventions in HRH training and social inequality in health

The fourteen documents selected which are related to Policies include legal documents, Ministry of Health interventions, the National Health Plans and reports supporting policies. These documents refer only to unequal social conditions (six) and widespread inequalities (eight) and none of these define inequality according to the concept used. Fewer texts were found for the first period (2000-2005), which only consist of legal documents, in which National Health Plans, both in Portugal69 and in Brazil70, deal with physicians, nurses and dentists, which shows a more specific approach as regards the other Plans, where health professionals are examined in more general terms7173. With respect to inequalities, these are dealt with mainly based on the typology of their unequal social conditions.

During the second period (2006-2012), we found a greater number (nine) and variety in the type of document available, since in addition to legal documents7476there are also the Ministry of Health interventions77,78, as well as technical reports supporting this policy7982. With respect to the latter, related to Brazil, three mentioned physicians, nurses and dentists and one dealt specifically with physicians and nurses, where inequality was presented in broader terms. This trend persists, in that the only legal documents from Brazil75 mention the same type of inequality.

The documents related to Portugal74,77,78deal with these professionals in a general way, with the exception of the PNS76, where health professionals are treated according to their professional category.


The findings of this survey indicate a predominance of theoretical studies and review of the literature conclude that scientific evidence can only contribute towards the introduction of and support to issues included in the political agenda.

Research findings can contribute with at least three of the stages involved in preparing policies: defining the agenda, establishing policies and implementation14. This process includes preparing recommendations made by decision-makers, which requires evidence about the effectiveness of the interventions, as well as many other forms of evidence9. An essential component of this process involves assessing the types of available evidence about health system interventions83.

Thus, through this study, we conclude that very little knowledge is produced that involves components to assess HRH training policies in general and considered as those related to the professionals being examined, with no scientific support available to enable policies to be based on evidence.

Identifying factors seen as essential to formulate policies for evidence-based social inequalities in health84,85 can occur in two ways: 1) politicians make use of scientific data on social inequalities in health so as to maintain this issue within the public agenda, since without data such problems remain invisible. Even so, scientific evidence should be presented in non-technical language; 2) policy-makers, scientists; health professionals, non-governmental organizations and the public join forces to introduce social inequalities in health into the public agenda. In this case, the scientific community can provide relevant evidence to enable equity strategies to be adopted, leaving it up to the policy-makers and health professionals to guarantee that these strategies are implemented86,87.

In both cases, the research findings should be presented to their target-groups in non-technical language. Likewise, in order to strengthen the findings of the research, it would be necessary to concentrate on the capacities of both the decision-makers and their teams to evaluate the applicability, and relevance of the results and quality of those studies88,89.

In order to use research findings to formulate and implement policies, it would be necessary to conduct studies to identify and evaluate how interventions have reduced social inequality through professional training. This review understands that the scarcity of research reflects the lack of policies that recognize professional training as a strategy to reduce inequalities. Furthermore, we noted that, in spite of an increase in scientific production during the period examined, many lacunae still exist, and that the knowledge production process and its relationship with decision-making could still become separate procedures, in both countries. This is precisely a question we will aim to answer in the second stage of this work.

In Brazil, few studies exist that seek to understand, even indirectly, how HRH training helps to reduce social inequalities in health. This is an issue raised by Bosi and Paim90, who discuss the main characteristics of professional training in the public health sector at undergraduate level; and Dias et al.91, who analyzed the history of a national policy for the reorientation of professional health training for the Unified Health System (SUS).

Over the last few years, new mechanisms have been established in Brazil that are designed to reduce inequalities not always related to scientific production, especially those found in the distribution of primary healthcare professionals, i.e., the Family Health Strategy. The study by Borde et al.46 showed that until the 1990s, in spite of the predominance of theoretical or conceptual research about health determinants, this helped place Brazilian research at the center of the political and academic agenda in Latin America. Even so, the scope and impact of social determinants in health and research into inequalities in health continue to be restricted to the academic community, with strong, though still insufficient implications in the formulation of policies and in health indicators46.

From the point of view of health training, more recent studies about undergraduate courses in public health92,93 discuss the process of its creation and implementation, seeing this as an irreversible reality in the field of interdisciplinary health training in Brazil, though pressured by traditional models of disciplinary training.

No studies were found in Portugal that establish a direct relationship between HRH and how this could eventually help reduce the social inequalities that still exist in health94. However, the organs that financed these investigations did not define this issue as a priority.

In the case of Europe, in 2013 the WHO95 presented six overall objectives for Health 2020: reduce premature mortality rates by 2020, increase life expectancy, reduce health inequalities, improve the well-being of the European population, provide universal health coverage and establish national goals for all member states. In other words, the fight against social inequalities in health will continue to be one of the priorities within the area of the European Union (EU), including Portugal, although this objective is not related to more specific lines of action, including what role should be played by HRH and their training.

All countries need consolidated systems to examine ways to help improve the health and well-being of their populations96. However, in Portugal there is still no health investigation system that guarantees a balanced scientific understanding of the national reality69 (National Health Plan 2004-2010, 69, p.79). It was only in 2006 that the "National Agenda of Health Research Priorities" was implemented in Brazil, the most important action of which was to legitimize the National Policy for Science, Technology & Innovation in Health (PNCTIS) in the country, in line with the principles of the SUS. This profile differs from that which occurs in other countries where there is already a well-established culture for funding agencies to provide support to incorporate evidence-based findings into political decisions97.

In recent years in Brazil, whenever a priority research agenda is being defined, part of this involves integrating the different actors into the process of knowledge production. Thus, in both the case of Brazil and Portugal, the findings of this study confirm the fragility of the relationship that exists between science and other areas of society, namely the health sector16.

This study also shows that there is a low level of integration between knowledge produced that is focused on training health professionals and social inequalities in health. That is, analytical studies tend to treat social inequality in health in a residual, indirect and latent manner, which can mean that full use is not made of evidence of social inequalities and, as a result, that this issue is not included in the policy agenda. The fact that funding agencies in Brazil give low priority to research that involves training, might well explain why there is a predominance of studies about HRH management that are unrelated to training.

We noted that, in the last two years, this trend has started to change, when the main funding agencies include studies about training in their research agendas. Even so, such agendas are still isolated and fragmented.

The current research agenda of the Department of Science & Technology (DECIT) includes the following components: training, with greater emphasis on user satisfaction; ongoing education; labor market analysis; calculating the size of the health labor force; regulations; workers and management of national training programs such as the Brazil Network of the National Telehealth Program (Telessaúde), namely the Program to Support the Training of Medical Specialists in Strategic Areas (Pró-Residência), the National Program for the Reorientation of Professional Health Training (Pró-Saúde), and the Education Program for Health Work (Pet-Saude); as well as research into medical demographics, migration, retaining and keeping resident physicians in the country98.

These initiatives can help ensure that their program priorities reflect the research work that has been developed in this area.

Final considerations

In summary, as regards Portugal, the relationship between inequalities in health and the training of health professionals mainly involves issues related to immigrants, which may reflect the more general concerns shown by the EU in this matter49.

In Brazil, the relationship between health professionals and social inequalities in health, in particular, the inequality in the distribution of these professionals is expressed through the work of professionals with vulnerable groups39, the insecurity and segmentation of working relationships between these professionals within the public health system99 and the fragility of health work market regulations100".

It is important to clarify that this study contains two limitations. The first relates to the nature of the data sources, specifically to the diversity of key word definitions found in the data banks. In line with other authors101,102, we also understand that certain features are inherent to studies which subjects are related to policies, with consequences on studies/documents selected and methodologies used. The second limitation concerns to the possible bias contained in published works103, since it is possible that, in the case of both countries, that we did not manage to trace all research papers issued or produced by the respective Ministries of Health, in the event that these were not made available on their respective websites.


To MRP, for the critical review of the final version of this article.


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Received: April 23, 2014; Revised: February 09, 2015; Accepted: February 11, 2015


IMR Craveiro worked on the concept of the study, methodology, document research, data analysis and on all versions of this article, including the review of the final version; VA Hortale, contributed to the concept of the study, methodology, document research, data analysis, and on all versions of the article, including this final version; APC Oliveira was involved in document research, data analysis, and all versions of this article; G Dussault on the study concept and on all versions of this article, including the text of the final version.

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