Precarization of work in healthcare and the impacts of labor reform on the National Occupational Health Policy: a scoping review

Abstract

Introduction  The precarization of working conditions in the healthcare sector, intensified after Brazil’s 2017 Labor Reform, has compromised the implementation of the National Occupational Health Policy (NOHP), particularly in Primary Health Care (PHC).

Objective  To review the literature on the impacts of the Labor Reform on the implementation of the NOHP, with a focus on PHC.

Methods  This is a scoping review. The search was conducted in PubMed, SciELO, LILACS, Web of Science, and gray literature sources (BDTD, CAPES, COFEN), including studies published between 2012 and 2024 in Portuguese, English, and Spanish.

Results  From an initial 510 records, 32 studies were included (14 from indexed databases and 18 from the gray literature). Findings revealed unstable employment arrangements, outsourcing, and high turnover, in addition to work intensification through overload and extended working hours. Reported impacts included health problems among workers, especially mental health disorders, and weaknesses in NOHP enforcement, which exposes PHC professionals’ vulnerability in the face of labor reforms.

Conclusion  Labor precarization compromises the implementation of the NOHP in PHC, highlighting the need for stricter regulation of outsourcing, more professional recognition, and reinforced of public policies.

Keywords:
Occupational Health; Primary Health Care; Working Conditions; Health Policy; Unified Health System

Resumo

Introdução  A precarização das condições de trabalho na saúde, intensificada após a Reforma Trabalhista de 2017 no Brasil, compromete a efetivação da Política Nacional de Saúde do Trabalhador e da Trabalhadora (PNSTT), especialmente na Atenção Primária à Saúde (APS).

Objetivo  Revisar a literatura atinente aos impactos da Reforma Trabalhista na implementação da PNSTT, com foco na APS.

Métodos  Trata-se de revisão de escopo. A busca foi realizada nas bases PubMed, SciELO, LILACS, Web of Science e literatura cinzenta, incluindo estudos publicados no período 2012–2024, nos idiomas português, inglês e espanhol.

Resultados  Dos 510 registros iniciais, 32 estudos foram incluídos (14 em bases indexadas e 18 na literatura cinzenta). Os achados evidenciaram vínculos instáveis, terceirização e alta rotatividade, além de intensificação do trabalho com sobrecarga e jornadas extensas. Destacaram-se impactos na saúde dos profissionais, sobretudo adoecimentos mentais e fragilidades na fiscalização da PNSTT, revelando a vulnerabilidade dos trabalhadores da APS diante das reformas trabalhistas.

Conclusão  A precarização do trabalho compromete a efetivação da PNSTT na APS, demandando um reforço na regulação das terceirizações, a valorização profissional e o fortalecimento das políticas públicas.

Palavras-chave:
Saúde do Trabalhador; Atenção Primária à Saúde; Condições de Trabalho; Política de Saúde; Sistema Único de Saúde

Introduction

The relationship between work and health is a central theme in discussions about social rights and public policies, especially in the context of the Brazilian Unified Health System (Sistema Único de Saúde [SUS]). The health care model adopted in Brazil recognizes that the work process can be a determining factor in both well-being and illness, depending on the working conditions in which it occurs. In this sense, the National Occupational Health Policy (NOHP), established by Ordinance No. 1,823/2012¹, aims to guarantee comprehensive actions for the promotion, protection, and recovery of workers’ health, considering the risks and problems related to productive activities and the work environment.

The NOHP establishes universal care as one of its fundamental guidelines, promoting access to health services for all workers, regardless of how they enter the labor market, whether formally or informally, the type of employment relationship, or the nature of the activity performed. In this sense, the NOHP seeks to ensure that workers with a formal contract, as those who are self-employed, temporary, cooperative, informal, and even unemployed have access to health actions and services that meet their specific needs¹. Moreover, this policy is aligned with with the principles of the SUS, such as universality, equity, and comprehensiveness, and proposes intersectoral strategies to reduce the impacts of work activities on workers’ physical and mental health².

However, the implementation of the NOHP faces important challenges, especially due to the growing precarization of labor relations in Brazil. In recent years, legislative changes, such as the 2017 Labor Reform (Law No. 13,467/2017)³ and the Outsourcing Law (Law No. 13,429/2017)⁴, have made historically won rights more flexible, allowing for more unstable forms of employment and weakening workers’ social protection. This scenario has led to an increase in informality, outsourcing and intensification of work, factors that have a direct impact on workers’ occupational health and quality of life⁵.

The precarization of work refers to the intensification of instability, informality, turnover, and unprotected employment relationships, promoted by flexibilization policies and the advancement of neoliberal logic in labor relations. This phenomenon is not restricted to the contractual aspect, but also affects psychosocial working conditions, intensifying the exploitation of the workforce and the risks to workers’ health⁶.

The 2017 Labor Reform³ promoted profound changes in the legal framework for labor relations, including the flexibilization of provisions in the Consolidation of Labor Laws (CLT), such as the prevalence of negotiated over legislated contracts, the regulation of outsourcing, and the expansion of intermittent contracts. These changes must be understood in the context of a reconfiguration of the role of the state, anchored in neoliberal ideals that promote the state’s lack of responsibility in guaranteeing social rights⁵.

The new National Primary Care Policy (PNAB/2017)⁷, by making the organizational arrangements of health teams more flexible, has also contributed to the consolidation of precarization in Primary Health Care (PHC). This policy, aligned with the principles of the Labor Reform, has made room for increasingly fragile and unstable employment relationships, compromising both workers’ rights and the continuity of care provided to the population⁷.

In this scenario, the precarization of work did not begin with the reform but was intensified by it. This phenomenon is characterized by unstable employment relationships, economic insecurity, informality, and lack of legal protection, and is closely linked to the financialization of production relations, in which work is transformed into a disposable asset, subordinated to the logic of capital profitability².

In the health sector, this phenomenon has been particularly worrying. Health professionals, such as doctors, nurses, technicians, and community workers, often work in adverse conditions, facing exhausting working hours, low salaries, multiple employment relationships and constant exposure to biological, physical, and psychosocial risks⁸. Outsourcing and the management of health units by Social Organizations (SO) and Civil Society Organizations of Public Interest (OSCIP) have also aggravated this situation, resulting in a high turnover of workers, a lack of stable employment relationships and a reduction in labor rights, factors that compromise both the health of professionals and the continuity and quality of care provided to the population⁹.

The precarization of health work not only has a direct impact on health professionals but also compromises the fundamental principles of the SUS. Work overload and job instability can lead stress symptoms, burnout, both physical and mental health disorders, an increase in absenteeism, and a reduction in the quality of care provided to users⁹. Furthermore, workers subjected to precarious conditions may find it difficult to access occupational health and safety policies, precisely because they are part of a model that denies formal employment protections and social rights, making it difficult to implement public policies aimed at protecting workers’ health¹⁰.

Given this scenario, it is essential to strengthen the NOHP as an instrument for protecting workers’ health and tackling work precarization. To this end, it is necessary to adopt structural measures that are committed to the principles of the SUS, such as: expanding the inspection of working conditions; restricting or prohibiting the outsourcing of end-activities in the health sector, which are often used as mechanisms for privatizing and financializing the public system; guaranteeing better salary and structural conditions for professionals; and ensuring the active participation of workers in the formulation and implementation of public policies. Coordination between unions, health councils, research institutions, and public managers is also essential to ensure that the NOHP is implemented and that strategies to protect workers’ health are improved¹¹.

It is worth noting that the Labor Reform was approved in the same year as the publication of the new National Primary Care Policy, in 2017, whose wording made the minimum composition of teams, organizational arrangements and the territorialization of PHC more flexible. This regulatory coincidence is not accidental but signals a convergence between neoliberal policies aimed at reducing the role of the state and expanding outsourced and contractualized management models, with direct impacts on employment relationships and the effectiveness of the NOHP⁷.

In this context, this study aims to review the literature on the impacts of the Labor Reform on the implementation of the NOHP, with a focus on PHC. International experiences have been also analyzed to identify strategies to strengthen the protection of occupational health in Brazil.

Methods

A scoping review was conducted according to the methodological framework proposed by Arksey and O’Malley, based on the recommendations of the PRISMA-ScR checklist (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews)¹². This approach allows us to examine the extent, breadth and nature of scientific production on a given topic, identifying gaps in knowledge and providing input for future research¹³,¹⁴. The review protocol was retrospectively registered on the Open Science Framework (OSF) platform, available at: https://osf.io/w7e58/. Although the scoping review does not require a formal assessment of the quality of the studies, a descriptive critical appraisal was carried out, considering the coherence between the objectives and results presented, the methodological suitability of the designs and the consistency of the evidence, to evaluate the robustness of the findings included.

Research question

The research was structured into five main stages: identification of the research question, selection of relevant studies, data extraction and mapping, synthesis and analysis of the findings, and presentation of the results. The guiding question was formulated based on the PCC (Population, Concept, and Context) strategy and was defined as follows: population - health workers, concept - implementation of the NOHP, and context - impacts of precarious labor relations after the Labor Reform¹⁴.

Search strategies

The literature search was conducted systematically and individually in the main scientific databases and gray literature sources, with the aim of guaranteeing the scope and sensitivity needed to identify studies relevant to the topic.

The following electronic databases were consulted: PubMed, Scientific Electronic Library Online (SciELO), Latin American and Caribbean Health Sciences Literature (LILACS), and Web of Science, as well as gray literature sources, including the Digital Library of Theses and Dissertations (BDTD), the Thesis Bank of the Coordination for the Improvement of Higher Education Personnel (CAPES), and the institutional repository of the Federal Nursing Council (COFEN).

In the PubMed and Web of Science databases, the search employed controlled descriptors from the MeSH vocabulary and free terms such as: “Occupational Health”, “Primary Health Care”, “Labor Reform”, “Precarization of Work”, and “Working Conditions”, combined using Boolean operators (AND, OR) to maximize the sensitivity and specificity of the strategy.

In the SciELO and LILACS databases, descriptors from the Descriptors in Health Sciences (DeCS) vocabulary were used, including the terms: “Saúde do Trabalhador” (Occupational Health), “Atenção Primária à Saúde” (Primary Health Care), “Precarização do Trabalho” (Work Precarization), “Reforma Trabalhista” (Labor Reform), and “Política de Saúde” (Health Policy), also combined with Boolean operators.

The inclusion of gray literature aimed to broaden the scope of the review and reduce publication bias, considering the relevance of academic and institutional documents that are often not available on indexed databases. The same descriptors were applied to the BDTD, CAPES, and COFEN platforms, with specific adaptations according to the interfaces and search mechanisms of each repository.

Documents and studies that explicitly addressed the precarization of health work and the implementation of the NOHP in the context of PHC were included, considering the period from 2012 to 2024, to reflect the contemporary advances and challenges of the subject.

We chose to delimit the time frame of the research to the period from 2012 to 2016, a phase prior to the enactment of the Labor Reform, but marked by important transformations in labor relations in Brazil. During this period, there were already regulatory initiatives, legislative debates, and institutional practices that indicated a trend towards more flexible employment relationships and increased precarization of work, especially in the public sector. Thus, precarization of work is understood as a structural phenomenon that predates the reform, which only intensified processes already underway. Analyzing this period provides insights to the preparatory context of the Reform, showing that the processes of deregulation and erosion of labor rights did not originate exclusively in the new legislation, but were gradually structured over the previous years. In this way, the adopted approach enables a broader understanding of the impacts on workers’ health, including the accumulated effects of the transformations that preceded the reform.

The results were screened according to pre-established eligibility criteria, including the reading of the title, abstract, and, when necessary, the full text, carried out independently by two reviewers, with differences being resolved by consensus.

In addition, language filters (Portuguese, English, and Spanish) were applied to the databases consulted. There was no initial restriction on the year of publication in the indexed literature, to ensure a broad and comprehensive review.

The search strategies were previously developed and adapted to the specificities of each database and repository, to ensure sensitivity and specificity in retrieving the studies. The combinations of controlled and free terms, structured with Boolean operators, are shown in detail in Table 1.

Table 1
Search strategies

Scientific databases
PubMed (MeSH descriptors and free terms)	(“Occupational Health”[MeSH Terms] OR “Occupational Health”[Title/Abstract]) AND (“Primary Health Care”[MeSH Terms] OR “Primary Health Care”[Title/Abstract]) AND (“Labor Reform”[Title/Abstract] OR “Precarization of Work”[Title/Abstract] OR “Working Conditions”[MeSH Terms])
SciELO (DeCS descriptors and free terms)	(“Saúde do Trabalhador” OR “Condições de Trabalho”) AND (“Atenção Primária à Saúde”) AND (“Reforma Trabalhista” OR “Precarização do Trabalho”)
LILACS (DeCS descriptors)	(“Saúde do Trabalhador” OR “Precarização do Trabalho”) AND (“Atenção Primária à Saúde”) AND (“Reforma Trabalhista”)
Web of Science (free terms)	(“Occupational Health” OR “Working Conditions”) AND (“Primary Health Care”) AND (“Labor Reform” OR “Precarization of Work”)
Gray literature
BDTD	(“Saúde do Trabalhador” OR “Condições de Trabalho”) AND (“Atenção Primária à Saúde”) AND (“Reforma Trabalhista” OR “Precarização do Trabalho”)
CAPES Thesis Database	(“Saúde do Trabalhador” OR “Condições de Trabalho”) AND (“Atenção Primária à Saúde”) AND (“Reforma Trabalhista” OR “Precarização do Trabalho”)
COFEN	(“Saúde do Trabalhador” OR “Condições de Trabalho”) AND (“Atenção Primária à Saúde”) AND (“Reforma Trabalhista” OR “Precarização do Trabalho”)

• DeCS: Health Sciences Descriptors; SciELO: Scientific Electronic Library Online; LILACS: Latin American and Caribbean Health Sciences Literature; BDTD: Digital Library of Theses and Dissertations; CAPES: Coordination for the Improvement of Higher Education Personnel; COFEN: Federal Nursing Council.

Eligibility criteria

We included studies published between 2012 and 2024, in Portuguese, English, or Spanish, which addressed the implementation of the NOHP in the context of PHC, considering the impacts of the 2017 Labor Reform and the effects of outsourcing models on working conditions.

Government reports and institutional documents addressing the implementation of the NOHP in the face of recent legislative changes were also considered, to ensure a comprehensive and up-to-date analysis.

Studies that dealt with workers’ health at other levels of care or that did not address the Labor Reform or its relationship with the NOHP were excluded.

Study selection process

The studies were selected in three sequential stages: (1) reading the titles, (2) reading the abstracts, and (3) reading the full texts. Inclusion and exclusion criteria were applied at the abstract and full text reading stages, ensuring that only studies aligned with the research question and thematic scope were retained.

Two reviewers (RCB and MRB) participated independently in all the screening stages, and any disagreements were resolved by consensus. The management of the references, the removal of duplicates, and the screening of the studies were carried out with the support of Microsoft Excel software, which facilitated to organize the references, systematically apply the eligibility criteria and transparently record all the decisions made in the selection process.

The information extracted from the included studies was organized into thematic categories, based on the main elements identified regarding the precarization of work and the implementation of the NOHP in PHC.

Data extraction, synthesis, and analysis

Data extraction was carried out systematically by two researchers (RCB and MRB) independently, with cross-checking to ensure consistent results. A pre-tested electronic spreadsheet was used, structured with the following variables: author, year of publication, country, type of study, target population, objectives, main findings, and implications for the implementation of the NOHP. The information extracted was organized in such a way as to allow the findings to be categorized by thematic axes. Any disagreements between the researchers were resolved by consensus.

The definition of the thematic axes resulted from an inductive analysis of the content extracted from the selected studies. Initially, an exploratory reading of the titles, abstracts, and full texts was carried out to identify recurring categories relevant to the implementation of the NOHP. Subsequently, these categories were refined and grouped into thematic axes, organized according to conceptual and operational dimensions pertinent to the object under investigation. Enabled a systematic organization of the findings , ensuring analytical coherence and a theoretical basis for discussing the impacts of the labor reform within the scope of the NOHP.

The data extracted was organized in spreadsheets and then consolidated using thematic qualitative analysis, grouping the findings into recurring categories, as detailed in the results section.

The variables extracted were: (i) Type of employment relationship; (ii) Working conditions; (iii) Management models (e.g. outsourcing, temporary contracts); (iv) Occupational health outcomes; (v) NOHP implementation strategies; and (vi) Barriers identified to the implementation of the NOHP.

It was assumed that the Labor Reform and the advance of outsourcing models would contribute to the precarization of labor relations, negatively impacting working conditions, contract stability and workers’ health outcomes, as well as creating barriers to the implementation of the NOHP.

The data was synthesized using qualitative analysis, with a focus on identifying patterns, challenges, and recommendations related to the precarization of health work and the obstacles faced in implementing the NOHP. The studies included were grouped into thematic categories according to the main recurring elements, such as unstable employment relationships, outsourcing, work overload, work-related illnesses, and gaps in the monitoring of public policies.

The discussion of the findings was based on theoretical references from the area of public policy, work, and health, with the aim of understanding the impacts of the 2017 Labor Reform on PHC professionals and identifying possible strategies for strengthening the NOHP in the context of the SUS.

Although a formal assessment of the methodological quality of the included studies was not carried out, a descriptive critical appraisal was conducted considering: coherence between objective and results, adequacy of the methodological design, and consistency in the presentation of the findings. This analysis sought to verify the robustness and relevance of the evidence mapped.

The descriptive critical appraisal considered the clarity in the presentation of the objectives and results, the adequacy of the methodological design, and the consistency of the evidence presented, even without the application of formal quality checklists, as recommended in scoping reviews.

Methodological limitations

According to the methodological guidelines for scoping reviews, the formal assessment of methodological quality is not mandatory, since the main focus is to map the extent and nature of the available literature on a specific topic. Therefore, it was decided not to formally assess the quality of the studies. However, a descriptive critical appraisal was carried out, considering the consistency of the findings, the coherence between objectives and results, and the suitability of the methodological designs used. It was observed that although most of the studies had a qualitative or review approach, the data revealed recurrent patterns regarding the precarization of working relationships and their impact on the implementation of the NOHP, giving robustness to the body of evidence mapped.

Results

The analysis of the selected studies enabled the mapping of the impacts of the 2017 Labor Reform (Law No. 13,467/2017), correlated to the NOHP, in the context of work precarization in healthcare. A total of 443 studies were identified in scientific databases and 67 studies in gray literature, totaling 510 initial records. After screening and applying the inclusion and exclusion criteria, 32 studies remained for final analysis, 14 from indexed databases, and 18 from the gray literature. The flowchart for selecting the studies is shown in Figure 1.

Figure 1
Flowchart of the selection process for the included studies

A total of 352 studies were excluded during the process: 115 for duplication, 187 after reading the titles and abstracts and 50 after reading the full texts because they did not meet the eligibility criteria.

After the final selection, 32 studies were included in this scoping review. Table 2 presents a summary of the methods, objectives, and main findings of each study included in the review, with information on the authors, year of publication, type of study, country, population investigated, objective, and main results related to the impacts of work precarization and the implementation of the NOHP.

Table 2
Main characteristics of the studies included in the scoping review (n = 32)

Author/Year	Type of study	Country	Population/professionals	Main objective	Main results related to precarization and NOHP
Sibbald et al., 200616	Literature review	United Kingdom	PHC nurses	To analyze the advanced role of nurses in PHC	Expansion of functions with increased workload
Mills et al., 201017	Qualitative study	Australia	Rural nurses	To assess the status of rural nursing after 12 years	Overload and lack of institutional recognition
Smith, 199018	Opinion study	USA	Health professionals	To discuss health policy in the USA	Fragility of the health system affects working conditions
Currie et al., 201919	Mixed study	Australia	Self-employed nurses	To evaluate the practice of self-employed nurses	Professional isolation and lack of institutional support
McDonald et al., 200920	Qualitative study	United Kingdom	PHC nurses	To analyze the effects of a new national contract	Intensification of care activities
Souza et al., 202321	Qualitative study	Brazil	Surveillance professionals	To assess perceptions of Chagas surveillance	Report overload, lack of staff and precarious infrastructure
Simas & Pinto, 201722	Cross-sectional study	Brazil	Community agents	To portray the working conditions of CHAs	Low pay, temporary contracts and job insecurity
Santos, 201123	Qualitative study	Brazil	PHC nurses	To contribute to the health of nursing workers	Identify physical and mental illness related to precarization
Racic et al., 201924	Survey	Bosnia	Nurses	To evaluate expectations and perceptions about work	Inadequate conditions and low satisfaction
Cote et al., 201925	Qualitative study	Canada	PHC nurses	To understand meanings attributed to work	Report emotional distress and overload
Ehlers et al., 200026	Case study	South Africa	Health professionals	To discuss politics and nursing in South Africa	Situations of vulnerability and social insecurity
Marceau et al., 202127	Qualitative study	Canada	PHC nurses	To assess the sustainability of funding models	Financial insecurity and temporary contracts
Rodrigues, 201728	Theoretical study	Brazil	PHC professionals	To discuss precarization as a bioethical issue	Identifies naturalization of precarization
Rocha, 201829	Qualitative study	Brazil	Social workers	To analyze working conditions in SUAS	Low appreciation and lack of institutional recognition
Ribeiro, 201930	Case study	Brazil	FHS professionals	To evaluate FHS	Excessive workload, fragile contracts
Silva, 202231	Institutional study	Brazil	PHC nurses	To analyze labor relations in a local management model	Precarious contracts, high turnover
Oliveira, 202032	Qualitative study	Brazil	PHC teams	To analyze collaboration between teams	Limited resources and weak links
Sousa Junior, 201933	Critical analysis	Brazil	Health professionals	To relate labor counter-reform and class struggles	Dismantling of labor rights
Fonseca, 202034	Case study	Brazil	PHC professionals	To analyze labor relations under management by SO	Fragile ties, high turnover
Vicente, 202035	Qualitative study	Brazil	PHC professionals	To analyze safe access strategies in the face of urban violence	Occupational overload and stress
Sousa, 201936	Qualitative study	Brazil	EFHC professionals	To evaluate the work process and workers’ health	Overload, precarious contracts and illness
Sá, 202237	Documentary study	Brazil	PHC professionals	To analyze public management and employment relationships	Precarization via temporary contracts
Orrillo, 201938	Ethnographic study	Brazil	Community workers	To study the training of community workers	Lack of labor rights and high turnover
Rosa, 202039	Qualitative study	Brazil	Care network professionals	To evaluate coping with violence	High emotional burden
Carneiro, 201940	Qualitative study	Brazil	Social workers	To analyze work in the EFHC	Precarious working conditions
Dimarzio, 201841	Quantitative study	Brazil	PHC workers	To assess absenteeism	High rate of sick leave
Almeida, 202142	Qualitative study	Brazil	FHS nurses	To analyze the repercussions of productive restructuring	Intensification of work, fragile bonds
Martins, 202143	Comparative study	Brazil/Spain	PHC nurses	To compare working conditions between Brazil and Spain	Greater precarization in Brazil
Jesus, 201944	Theoretical essay	Brazil	Nurses	To reflect on the precarization of nursing	Low salaries and overload
Pereira et al., 202245	Documentary study	Brazil	Nurses	To analyze the impacts of the Labor Reform on nursing	Loss of labor rights
Lopes et al., 202346	Documentary study	Brazil	PHC workers	To assess the organization of the PHC workforce	Reduction in stable jobs and increase in outsourcing
Barreto & Mendes, 202347	Qualitative study	Brazil	Health professionals	To assess overexploitation during the pandemic	Intensification of working hours, increase in mental illness

• Note: NOHP: National Occupational Health Policy; PHC: Primary Health Care; USA: United States of America; CHA: Community Health Agent; EFHC: Expanded Family Health Center; FHS: Family Health Strategy; SUAS: Unified Social Assistance System; SO: Social Organizations.

During the screening process, 352 studies were excluded due to their inappropriateness to the topic or failure to meet the eligibility criteria, as detailed in the Figure 1 - Flowchart of the selection process for the included studies.

Characterization of studies and bibliometric data

The research revealed that most of the studies reviewed were published in Brazil, corresponding to n = 23 of the total, followed by: Canada, the United Kingdom, and the United States of America. The predominance of national studies reflects the relevance of the subject in the Brazilian context, where recent labor reforms and changes in public management models have directly impacted working conditions in PHC⁶.

Moreover, it was identified that most of the research was conducted through literature reviews (n = 15), followed by qualitative (n = 14), quantitative (n = 1), and quantitative-qualitative (n = 2) studies. The analysis also highlighted that nursing professionals were the most studied, accounting for (n = 14 studies) of the research reviewed, while (n = 18 studies) included health professionals in general⁴²,⁴⁷. This distribution suggests an emphasis on the precarization of nursing work, a category historically marked by low salaries, multiple employment relationships, and work overload⁴⁸,⁴⁹.

This predominance, however, is not indicative of a research bias, but reflects the centrality of nursing in the health system and the significant production of studies on this professional category in the repositories consulted, including gray literature. The inclusion of documents from COFEN was justified by the institutional relevance of this council and the significant volume of productions dealing with the precarization of work in nursing. Thus, the emphasis observed in the studies on this category emerges as a characteristic of the available literature itself, consistent with the methodological criteria established for this review.

Challenges in implementing the NOHP in PHC

The data analyzed indicates that the precarization of work has hindered the implementation of the NOHP, especially in PHC. Professionals under temporary or outsourced contracts face job instability and often do not have full access to social security, including social security rights such as retirement, sick pay, and maternity leave. In many cases, these workers are not linked to the General Social Security System or contribute irregularly, which compromises their protection in situations of sick leave or disability. Furthermore, work overload and high turnover negatively impact continuity of care, damaging the relationship between professionals and PHC users¹⁰.

The inspection of the NOHP also has structural flaws. The small number of labor inspectors and the lack of specific regulations for workers’ health in the public sector make it difficult to effectively implement the policy⁵. In addition, Constitutional Amendment 95/2016, which imposed a ceiling on public spending, reduced investments in the area, further compromising inspection¹⁰.

International experiences of worker protection

Some international experiences can serve as valuable reference for improving the NOHP. In countries such as Canada and Sweden, health protection for workers is reinforced by job stability policies and strict regulation of outsourcing⁹. In the UK, the Health and Safety Executive (HSE) acts to continuously monitor health working conditions, ensuring that employers comply with strict safety and welfare standards⁵⁰.

In Brazil, the adoption of similar strategies could strengthen the NOHP. The expansion of inspection, the regulation of outsourcing in the SUS, and the implementation of career plans for PHC professionals are essential measures to ensure the effectiveness of the policy.

Impacts of precarization on occupational health

The findings of the studies analyzed show that work precarization in the health sector is associated with rise in both mental and physical health issues among PHC professionals. Among the main impacts reported are burnout syndrome, occupational stress, anxiety, and depression, problems widely attributed to work overload, contractual instability, and the lack of suitable conditions for performing their duties⁴⁶.

The literature reviewed shows that outsourcing has been a determining factor in this process, promoting the fragmentation of employment relationships and reducing the labor rights of health professionals. Studies indicate that the presence of Social Organizations in public health management has led to high turnover of workers, weakening the continuity of services and negatively impacting the quality of care provided to the population⁵¹.

Other relevant aspects identified were the wage gap and the need for multiple jobs to guarantee a minimum level of income. Many PHC professionals reported exhausting working hours, often exceeding 40 hours a week, aggravating absenteeism rates and sick leave⁵². Moreover, several studies point to the lack of career plans as an aggravating factor in professional instability, contributing to the devaluation of work in PHC and making it difficult to retain qualified professionals. This dynamic compromises the quality of care offered by the SUS and hinders the implementation of health promotion and prevention strategies⁴⁵.

The relationship between the NOHP and the protection of health workers

Although the NOHP establishes guidelines for the promotion of workers’ health and the prevention of work-related illnesses, the studies analyzed indicate that its implementation has been limited. The lack of adequate supervision and the underfunding of public social protection policies contribute to the perpetuation of precarious work in the health sector²⁸.

Furthermore, the lack of a national public policy on employment relationships and careers for PHC professionals has contributed to the proliferation of precarious and fragmented employment relationships. This myriad of forms of contracting, which includes temporary contracts, outsourcing, contractual relationships, and pejotização (Brazilian concept of hiring workers as independent contractors through their own legal entities), not only increases the job insecurity of workers, but also compromises the public dimension of the SUS by weakening the continuity of care, state accountability and the stability of health teams³¹.

Given this scenario, several studies suggest the need to enhance the monitoring of working conditions in health, ensure the effective application of the NOHP, and establish policies that value PHC workers. This valorization should include, for example, the implementation of structured career plans, public examinations as a priority way of entering the service, wages compatible with the complexity of the work, and adequate conditions for professional practice, ensuring stability, continuing training, and participation in management spaces³⁶.

The data analyzed point to a gap in the literature regarding the relationship between precarization of work and the set of labor reforms implemented in Brazil, especially since 2017. These include the Labor Reform (Law No. 13,467/2017), the Outsourcing Law (Law No. 13,429/2017), and changes to social security legislation and hiring models in the public sector. There is a need for more research to further investigate of the effects of these changes on the health of PHC workers, as well as the effectiveness of the NOHP as an instrument of protection against precarization.

The results obtained in this study show that the precarization of work in the health sector has a direct impact on the quality of life of professionals in the sector and compromises the effectiveness of the NOHP. High worker turnover, fragmented employment relationships, and work overload are challenges that need to be tackled through stricter public policies and more efficient monitoring of working conditions.

The precarization of work in PHC represents a structural obstacle to the implementation of the NOHP. This policy, which is geared towards promoting healthy working environments and making health managers accountable, faces operational difficulties precisely in regions where outsourcing and contractual instability predominate. The turnover of professionals, fragile employment relationships, and under-reporting of work-related illnesses limit surveillance actions and continuous care for SUS workers, weakening the pillars of the NOHP and making its guidelines unworkable in the day-to-day reality of PHC⁷.

In this way, the data shows that the distance between the NOHP guidelines and the reality experienced by PHC professionals reflects a structural contradiction in the system. This tension will be critically analyzed in the following section.

Discussion

The results obtained in this study highlight the challenges faced in implementing the NOHP in the context of the precarization of health work. The analysis of the literature revealed that the labor reforms, especially Law No. 13,467/2017, have had a significant impact on the flexibilization of labor relations, promoting the expansion of outsourcing and the deregulation of workers’ rights. These factors contribute to the intensification of the exploitation of the workforce and the deterioration of working conditions, especially in the health sector, where the work overload and turnover of professionals are growing⁵³,⁵⁴.

The precarization of work can be understood as a structural phenomenon of capitalism, exacerbated by neoliberal policies that seek to reduce labor costs to maximize profits. In the health sector, this is reflected in the hiring of professionals through Social Organizations, the fragmentation of employment relationships, and wage instability, factors that negatively impact both workers and the quality of services provided to the population⁵². Instead of guaranteeing rights, this management model has deepened social inequality and compromised the effectiveness of workers’ health policies³⁴,⁵⁵.

This outsourcing process is linked to the financialization of public health management, in which work and contracts are converted into instruments of profitability. The Social Organizations management model operates within the logic of fictitious capital, transforming the workforce into a commodity and increasing the profit margin on public resources, especially in primary care services. Constitutional Amendment 95/2016, by imposing a spending ceiling, has acted as a catalyst for this process, further weakening the state’s ability to protect workers and guarantee the public nature of the SUS³⁴,⁵⁶.

The financialization of healthcare is a strategic axis of capital, in which precarious work is a necessary condition for transforming public contracts into profitable financial assets. In this sense, the logic of profitability replaces the logic of care, subordinating public policies to the interests of the financial market⁵⁶.

It is important to note that precarious contracts in PHC are not limited to formalized outsourcing, but include forms such as hiring via Social Organizations, temporary contracts, and pejotização - the latter intensified in the last decade as an alternative to contain reduce labor costs. Although legally distinct, all these modalities share the characteristic of making labor guarantees and state accountability more flexible. A national study with PHC doctors showed that pejotização is perceived as a factor of job insecurity and devaluation, compromising the continuity of care and the belonging of professionals to teams⁵⁷,⁵⁸.

The analysis of the selected studies also revealed that precarious working conditions in healthcare directly affect the physical and mental health of professionals. Work overload, combined with unstable contracts and low pay, has been identified as one of the main causes of the increase in cases of work-related mental disorders, such as burnout syndrome, anxiety, and depression⁸. The erosion of union power and the absence of effective protection mechanisms have made it increasingly difficult for workers to organize and advocate for improved working conditions¹¹.

Another relevant factor identified was the intensification of work, resulting from the growing demand for productivity and the reduction in the number of professionals. Many health workers reported exhausting working hours, often more than 40 hours a week, without proper financial compensation or support from their employers. The absence of institutional support, expressed in the lack of adequate sizing of the workforce, occupational health protection mechanisms, and active listening, contributes to the naturalization of work overload, increasing the physical and emotional exhaustion of professionals. This increase in working hours and responsibilities, without the corresponding professional appreciation, reflects a management model guided by the logic of maximizing efficiency to the detriment of workers’ well-being⁴⁷.

By establishing guidelines for the promotion of occupational health, the NOHP should act as a protective mechanism against this process of precarization. However, the results indicate that its implementation has been limited by the lack of government oversight and investment. The lack of public policies to guarantee job stability and security contributes to the perpetuation of a hostile working environment, in which workers are forced to accept adverse conditions to keep their jobs¹.

In addition, the literature analyzed points to the need to review health outsourcing policies. Unrestricted outsourcing has led to the fragmentation of services, jeopardizing the continuity of care and compromising the relationship between PHC professionals and users. The high turnover of workers in health units has a direct impact on the quality of care, as it makes it difficult to establish links between the team and the community served⁵⁴,⁵⁹.

The precarization of health work is also associated with an increase in absenteeism and sick leave. Professionals subjected to unhealthy working conditions, excessive workloads and constant pressure to meet targets are more likely to develop physical and mental illnesses. This phenomenon results in a vicious cycle in which the departure of sick workers puts an even greater burden on those who remain at work, exacerbating the crisis in the public health system⁶⁰.

Given this scenario, it is urgent to strengthen the NOHP as an instrument for protecting and valuing health workers. Measures such as stepping up inspections of working conditions, regulating outsourcing and implementing career plans with stability and adequate pay are essential to guarantee a fairer and healthier working environment⁵⁹,⁶⁰.

However, it is necessary to recognize that isolated regulatory measures, such as greater oversight of outsourcing, are insufficient if not accompanied by a political and strategic repositioning that tackles the structural causes of precarization. Proposals such as career plans and wage increases, although important, should not be dissociated from the uncompromising defense of a public, state-owned and universal SUS, free from the constraints of market-oriented logics⁵⁹,⁶⁰.

Moreover, it is essential to encourage the participation of workers in the formulation and implementation of occupational health policies, ensuring that their demands are effectively considered⁵⁶,⁶⁰.

These findings are in line with recent studies published in the Brazilian Journal of Occupational Health (RBSO), which discuss the precarization of labor relations and their effects on workers’ health in Brazil⁴,⁵.

The challenges faced by the NOHP reflect the complexity of the struggle for labor rights in the context of increasingly flexible labor relations. The effective implementation of this policy requires a joint effort between public managers, trade unions, researchers, and civil society to ensure that workers’ health is recognized as a fundamental right and an indispensable condition for the quality of services provided to the population.

Limitations of the study

This scoping review has some limitations. Firstly, the absence of a formal assessment of the methodological quality of the studies may limit the robustness of the inferences. Secondly, the inclusion of gray literature, despite broadening the scope, may have introduced variability in the quality of the documents. Thirdly, the geographical concentration of the studies in Brazil restricts the international of the findings.

Furthermore, some of the studies included had intrinsic methodological limitations, such as restricted samples or lack of robust quantitative data, which may compromise the validity of the results.

Conclusion

The review revealed that the NOHP faces significant challenges in its implementation, especially in the context of precarious labor relations, including those in the health sector. The flexibilization of labor relations, intensified by the 2017 Labor Reform, has contributed to the expansion of outsourcing, the fragmentation of employment relationships and the worsening of precarious working conditions, directly affecting PHC professionals and compromising the quality of services delivered to the population.

The impacts of precarious work extend beyond contractual instability, reflected in work overload, an increase in mental health disorders related to working conditions, and the weakening of workers’ collective organization. The high turnover of health professionals, associated with temporary contracts and the absence of structured career plans, compromises the continuity of care and makes it difficult to build bonds between the teams and SUS users. These factors contribute to a deterioration in the working environment and a reduction in the effectiveness of the actions carried out in PHC, contradicting to the fundamental principles of the NOHP and the SUS itself.

The study also revealed that although the NOHP establishes important guidelines for the promotion of workers’ health, its effectiveness is limited by the lack of rigorous inspection and the underfunding of public policies. The lack of specific regulations to curb unrestricted outsourcing and guarantee adequate working conditions for health professionals demonstrates the need to reformulate and strengthen social and labor protection strategies in the sector.

In addition, the survey indicated the need for greater worker participation in the formulation and implementation of occupational health policies. The weakening of unions and representative organizations, driven by changes in labor legislation, has reduced the ability to demand better working conditions, making professionals more vulnerable to abusive practices and the structural precarization of the health sector.

Faced with this reality, we recommend strengthening the mobilization and struggle of workers to monitor the expansion of mechanisms for inspecting working conditions in the SUS, strengthening the demand for a review of the rules regulating outsourcing and the adoption of policies that value health professionals, guaranteeing stability, fair pay and access to continuous training programs. The strengthening of the NOHP must be based on the guarantee of labor rights, ensuring that health workers, who are responsible for caring for the population, have decent conditions in which to perform their duties.

These results reinforce the need for intersectoral actions that bring together managers, workers and social control bodies, such as Health Councils and the Workers’ Health Reference Centers (Cerest – Centros de Referência em Saúde do Trabalhador), to implement the NOHP guidelines and ensure decent working conditions within the SUS.

Finally, this study contributes to the understanding of the impacts of work precarization in the health sector and reinforces the importance of effectively implementing the NOHP as a structuring instrument for protecting workers in the sector. However, further research is needed to deepen the analysis of employment relationships and the impacts of precarization on the mental and physical health of PHC professionals, enabling the development of more effective strategies for valuing health work in Brazil.

Addressing precarization in PHC requires more than managerial improvements or specific regulations on forms of employment. It requires political choices that break with neoliberal rationality and directly confront the privatist interests that capture and commodify the public health system. The financialization of health, supported by policies to make the state unaccountable, is a structural axis of the crisis of work in the SUS.

In this context, not only is the employment model at stake, but also the very project of society and public health that seek to consolidate. Overcoming “quasi-neutrality” requires policymakers, researchers, health workers and academics to make an ethical and political commitment to the radicalization of the right to health and decent work, guided by the uncompromising defense of a public, universal and state-based SUS.

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• Information on academic work:
  Work derived from the master’s thesis “O trabalho na Atenção Primária em Saúde no contexto de Reformas Trabalhistas: uma revisão de escopo” (Work in Primary Health Care in the context of Labor Reforms: a scoping review), defended in 2024 at the Graduate Program in Nursing at the University of São Paulo by the author Rebeca Camille Bernardes.
• Data availability:
  The entire dataset supporting the results of this study has been made available in the OSF (Open Science Framework) repository and can be accessed at https://osf.io/w7e58/.
• Presentation at a scientific event:
  The authors declare that the study has not been presented at a scientific event.
• Funding:
  The authors declare that the work was not subsidized.

Edited by

• Editor-in-chief:
  Leila Posenato Garcia

Data availability

The entire dataset supporting the results of this study has been made available in the OSF (Open Science Framework) repository and can be accessed at https://osf.io/w7e58/.

Publication Dates

• Publication in this collection
  14 Nov 2025
• Date of issue
  2025

History

• Received
  24 June 2025
• Reviewed
  28 July 2025
• Accepted
  31 July 2025