Planning and Sizing of the Health Workforce in Brazil: advances and challenges

This study aims to analyze the production of knowledge about Planning and Sizing of the Health Workforce (PDFTS) developed in Brazil, identifying models and methodologies that consider the Guidelines of the Unified Health System (SUS) for the constitution of regionalized care networks. This is an integrative review, including Brazilian studies and full text, in Portuguese, and available in the CAPES, BVS and Google Scholar databases. The searches returned 48,083 documents and, after selection with the PRISMA strategy, 62 studies published between 2011 and 2020 were included. Most of the analyzed productions approach the PDFTS with comparative analyzes between the estimated needs and the current availability, being more frequent the studies of only one professional category, with emphasis on nursing. The findings contribute to the debate on the essentiality of the health workforce for the conformation of networks, by demonstrating that the calculation methods favor the use of indicators and parameters related to the provision of services in specific health facilities, especially hospitals, not operationalizing aspects of regionalization and systemic integration of the Health Care Network.


Introduction
The Planning and Sizing of the Health Workforce (PDFTS) is the process that systematically and continuously evaluates the workforce needs, resulting in the adequate number of people to perform the activities according to planning, strategic objectives and institutional policies 1 .
The planning of health actions and services of the Unified Health System (SUS) should ensure the acknowledgement of health conditions and determinants, policy formulation and assistance to people by means of the formation of integrated and regionalized networks 2 . The organization of the Health Care Network (RAS) reduces the fragmentation of the system and enhances the integration, continuity and coordination of care 3 . RAS operation is dedicated to the population and to the specified health region, and has as attributes the operational structure, organized in three levels of care (primary, secondary and tertiary), the health care model and the existence of an adequate, competent, committed Health Workforce (SF) with incentives to achieve the objectives of the system 4 .
Thus, PDFTS is a relevant problem concerning Health Work Management (GTS). It stimulates researchers to better understand the process of predicting and assessing personnel number and quality and is a powerful tool to boost the composition of teams that assist in the transformations necessary for SUS 5, 6 consolidation.
That said, this study does not opt for an exact concept of PDFTS. Here, we broadly consider the actions and strategies to quantify the workforce in a given territory, service or health system, comprising the many faces of activities that precede and compose PDFTS. It recognizes that the structure of FTS as to RAS formation is a challenge 5 and that studies on this subject are essential to the understanding of paths under implementation in the health system.
The literature identifies PDFTS need to contemplate all levels of care, meet demands related to demographic and epidemiological transitions 7 , and to promote discussion on the scope of action of professional categories and actual needs of services and population 8 , as well as broader research to strengthen evidences that support decisionmaking on personnel estimation models as for health 9 .
Although the preparation of studies on health planning concerning public health tends to be influenced by political events such as the publication of new regulations 10 , the scientific production on PDFTS between 1964 and 2013 depicted the tendency to use normative methods based on economic issues and concentrated in hospitals, despite the various social and political scenarios over the period 8 .
Thus, it is worth mentioning that the policy of dividing in regions and organizing in networks carried out in SUS was propelled and renewed between 2010 and 2011 by means of the publication of new legal norms bringing concepts and guidelines as for RAS structuring with emphasis on users as the fundamental of care, and provision of actions planned and organized as regards to the population health needs; the horizontal relations between the points and levels of health care, with different roles, albeit the same importance; and multi professional care 4, 11 . From this perspective, it is relevant to update the literature review on PDFTS that identifies its relations with RAS structuring in Brazil.
This study investigates publications on the subject with the aim of identifying models and methodologies applied in Brazil that regard health regionalization, the different services and levels of care, and multi professional care.

Methodological path
An integrative literature review was conducted 12 with the purpose of answering the following question: 'What FTS planning and sizing methodologies are under development in Brazil?'.
The time frame from 2010 on considered the hypothesis that RAS guidelines standardization 4 , which occurred that year, affected the forms of PDFTS in Brazil. The choice of publications dealing with this issue was based on the understanding that SUS specificities of functioning and organization are applied solely in Brazil.
The investigation was carried out by means of electronic databases contained mainly in the Virtual Health Library (VHL) and in the Portal of Journals of the Coordination for the Improvement of Higher Education Personnel (CAPES' Portal of Journals). Relevant publication that might not be found in the scientific literature were also sought. Thus, the bases available in Google Scholar were additionally used.
Aiming at greater sensibility, broad search strategies using keywords and alternative terms selected from the Descriptors in Health Sciences (DeCS) edition 2020 were created, as well as expressions that, although not standardized, are often used to address this theme in the field of collective health, as explained in table 1. As for data collection, researchers carried out the initial search between October and November 2020, scheduling alerts in the databases whenever new documents were inserted by the end of that year. A -("downsizing organizacional" OR "dimensionamento de pessoal") AND (SuS OR saúde) 'title, abstract, subject' 'any + 'contains'. -B -"health workforce" OR "human resources in health" OR "administration of human resources in health" OR "human resources management in health" OR "assessment of human resources in health" OR "staff turnover" OR "personnel administration" OR "human resources administration" 'subject descriptor' 'no subject' + 'contains' -C -("workforce planning" OR "workforce sizing") AND (health OR SuS) 'title, abstract, subject' 'any' + 'contains'. 'with the exact phrase' + 'with at least one of the words' Source: Prepared by the authors.
Initially, the inclusion criteria were the Brazilian studies published between 2010 and 2020 dealing with the theme of FTS planning and sizing and providing full text in Portuguese. Abstracts and presentations without full texts, editorials and duplicate documents were excluded.
The documents found in the databases were selected during the search process by means of the filters available in each data source. Then, the researchers performed the screening of the eligible documents. The pre-selection was carried out by two different groups of three researchers each by the reading of the title and, whenever necessary, the abstract of all documents, as to provide greater specificity. Subsequently, meetings were held between the groups so to decide which documents would be selected for full reading in the exploratory phase. It was also decided that the documents found referring to a book chapter or to a piece of larger material, such as a report or event, would be read in full and, according to the inclusion and exclusion criteria, would be analyzed and catalogued as individualized materials, whenever appropriate.
During the exploratory phase, the complete reading of each material was carried out by all researchers so to identify the adequacy and coherence of the data systematization instruments and the analysis categories previously proposed, as well as the ability to answer the research question. The intention was to avoid losses by not clearly identifying the actual content by reading solely titles and abstracts and, at the same time, to expand the conditions to better specify the study. This phase allowed for the characterization of the knowledge production on the subject. It also revealed that several documents approached the subject indirectly, analyzing parameters that can be useful for the process or, for example, only quoting methodologies, although the authors used keywords related to PDFTS.
Then, the sample was debugged by only including the studies that evidenced the ability to answer the research question, i.e., those that explored or applied one or more PDFTS methodologies and described in the text body the method used. It was decided to exclude from the final selection the review studies and those published in 2010, for all were written before the aforementioned SUS standardization of RAS.
The information extracted from the selected studies were cataloged and systematized in the Microsoft Excel program, and classified according to the study approach; the professional categories involved; and the model or calculation method applied to FTS sizing and its relation to health regional division, to the care model and to RAS services or level of care.
Due to being a bibliographic study, it was not required to be submitted to the Research Ethics Committee, while respect for ethical aspects was granted in all phases of the research, following the provisions of the National Health Council 13 .

Results and comments
The searches retrieved 48,083 documents, of which, after the selection process that included the full reading, 62 publications were the subject of this review (figure 1). At least one was found in each of the ten years investigated; the lowest number of publications occurred in 2014 and 2019, being two in each year, while the biggest number of thirteen works were published in 2020. In this latter, although the highest volume of productions (20.9%) could be linked to GTS efforts to provide personnel to meet the demands caused by COVID-19, a single study was related to the pandemic 14 .
Among the selected productions are monographs (24.2%), journal articles (37.1%) and other kinds of documents, such as book chapters, technical reports and others, which, together, equate to 38.7% of the selected sample ( figure 1). This distribution reflects the characteristic of knowledge dissemination as for health planning in Brazil, most often found in technical documents and books 10 .
The total of 179 authors were involved in the analyzed productions, noting that the five most frequent ones are nursing graduates. So, most articles were published in journals of this area (69.6%). The remaining were found in journals of collective health (13.1%), administration, management and policies (8.7%), health sciences (4.3%) and speech therapy (4.3%). It is noted that this characteristic confirms a higher frequency and volume of productions on nursing personnel sizing in PDFTS studies and trials in Brazil 8 , even when the health field was not the only under observation, since 45% of the publications on econometric models of workforce projection in Brazil were found in nursing journals 9 .

Approaches
Three different approaches to PDFTS were identified in the studies. The first focus on recognizing the required workforce. Among the studies with this approach, only one aims, exclusively, to show the estimate of personnel need by hospitals 15 , while the remaining involve broader productions, either by defining minimum standards 16 or proposing methodology 17 and development of tools 18,19 that enable these estimates carrying out. The second approach refers to the workforce diagnosis and is present in studies that intend to collect information on the current FTS in a given geographic space, service or health region, mapping its composition and distribution 20-23 or profiling its personnel 24 .
As a result of sizing, the learning of differences between the planned and the existing workforce 25 is expected. Thus, several publications 26-30 disseminate the PDFTS experiences, where to ascertain of also the existing workforce as the estimated one as ideal or necessary are performed, thus combining the two approaches aforementioned and providing a comparative analysis.
The comparative analysis was the third approach observed and the most frequently accounted (84%). In this regard, comparisons were also provided between workforces at different times, premises or places, with emphasis to some publications that list the differences in FTS composition or distribution among municipalities regarding their size 31 , among public and private health subsystems, and among the regions of Brazil 14 . Other studies 32-36 described and analyzed FTS historical evolution of a given service or level of care as preparatory activity or phase of the PDFTS process.
This approach is useful not only for the production of thinking on PDFTS but also for putting reality under context, assisting in the decision-making and the continuing education processes related to GTS 33 .

Professional categories and occupations
The actions on which the population health care depends involve a broad set of workers who are addressed to various occupations 14 .
Regarding the inclusion of these workers, there was a predominance of studies that include only one professional area or occupation (62.9%).
Most studies account only for nursing (26). Of these, the majority (22) refers exclusively to hospital care ( The focus of the studies on nursing personnel corroborates the findings of previous systematic reviews 7,9 , which, when identifying FTS sizing methodologies, found that 66.6% 9 and 78.6% 7 of the studies addressed this area. The nursing area is essential to health services and is internally dependent on nurses, auxiliaries and nursing technicians 39 . It should be noted that, when assessing the 26 studies with this focus, it was found that all approached the whole team, without excluding any of the categories. Some even included, as part of the team, subcategories not predicted in the nursing personnel sizing regulated by COFEN 16 , such as nursing students 40 and caregivers 17 .  Among the remaining productions addressed to only one profession or occupation (table 3), stand out those of higher education level training: most refer to physicians (9), two are dedicated to speech therapists, and one to pharmacists. A study reports the PHC administrative personnel sizing, reinforcing their relevance for the Basic Health Units (UBS) 26 operation.
The authors consider the analysis of the medical workforce a challenge characterized by the scarcity of Brazilian studies on the subject and the lack of information pattern in data sources available on these professionals 58, 59 . Therefore, the studies retrieved are extremely important to create knowledge and overcome such limitations.
Although physicians, dentists and nursing professionals traditionally occupy most of Brazil' FTS, the involvement of other professions has gradually increased over the years, especially in PHC 32,34 . Nascimento' study 60 evinces, for example, the relevance of criteria creation as for the sizing of speech therapists to function in network, while Soares 23 reveals the growth of pharmacists' engagement at the municipal level. Thus, these studies contribute to broaden the debate on PDFTS, standing out the role of other professions in FTS structure and raising questions about more updated team arrangements in SUS. * this is a proposal applicable to any territory.
All 14 health professions recognized in Brazil 67 were found in the set of selected studies. In general, nurses and physicians were more frequent, while physical education professionals were the least cited. Table 4 lists the selected publications addressing the workforce of several occupations in the same study (37.1%). Such publications, when guided by the perspective of teamwork, seem to approach the fundamentals of multi disciplinarity and multi professionality that enable FTS diversification 32 .
As to Peduzzi et al. 68 , teamwork brings strategic components and reinforces characteristics necessary to face the increasing complexity of health needs, organization of services and networking health care systems, aiding the improvement of health care quality of the population.
In this regard, one can note two articles that analyze all health professions, identifying their presence 32 , growth and regional distribution in PHC 36 context, a level of care considered a coordinator of care and strategic to implement the care model.
Broadening the vision beyond these 14 professions, Mora and Rizzotto 21 include, in the analysis of FTS composition and distribution, the remaining workers with specific health training, as technicians in nutrition and clinical pathology. FTS studies on public hospitals in the State of Tocantins included all occupations involved in the care of users, even those that are addressed to indirect support, such as managers, porters and electrical technicians 33,69 , but not hierarchizing workers as to the level of education. Table 4 also summarizes that 43.5% of the studies including more than one occupation in PDFTS explicitly consider workers of all levels of training, recognizing, in practice, the diversity of categories that the health work process complexity requires. However, it is noteworthy that the production of knowledge in this sense is not yet significant in the scientific literature, since only one of these cases was published in a journal 30 . The remaining ones were mostly published in books, confirming the need to expand the dissemination by means of scientific

Health workforce sizing models and methods
Regarding the way of sizing, that is, the way of calculating and verifying the number of workers, studies have varied, spanning between those that contain detailed mathematical expressions that lead to a result and those that conceptually describe the steps or stages of the process, without disclosing the complete calculation or the result of a practical application.
Tables 2 to 4 reveals the predominance of studies carrying out the survey of the existing workforce without a pattern methodology or even recognized by specific terminology. Some studies calculate the workforce by applying secondary data available in local and national information systems 20,34,69 , while others make direct observation of the work schedules of each health unit investigated 26, 66 , either in number of people or hours of one professional.
Looking differently, the structuring of SUS increasingly moves towards the imperative of PDFTS reference models that overcome the standardization of an ideal number per service, standing out for the complexity of this process and the uniqueness of the work and health care technologies as to health needs and the referring population 79 .
The second approach frequently used for PDFTS among the selected publication relates directly to the predominance of nursing studies. They are applications of the models recommended in resolutions issued by the professional supervisory body, COFEN. Although the authors refer to those resolutions themselves as a method, Resolution No. 293/2004 particularly uses a methodology developed by Gaidzinki and Fugulin. In its most recent version, Resolution No. 543/2017 mentions the various references on which the recommendations for each area are grounded 16 . It was used to describe each study in table 2.
The aforementioned legislation determines the guidelines to estimate the number of nursing personnel required following the characteristics of the services, the nursing work processes, and the users' clinical conditions, regarding the workplace and, mainly, the degree of dependence and workload demanded for a given type of service 16 . It is also a reference for studies that do not use the calculation method indicated therein but are based on their parameters of technical safety index and minimum proportion between nurses and nursing technicians or auxiliaries, as seen in the studies developed by Borges et al. 51 , Souza et al. 56 and Teixeira 53 , where the methodology of Inoe and Matsuda was applied.
Research on sizing of nursing has scientific and social relevance, because, once it enables adequate qualitative-quantitative results, it can provide improvements in people's care 56 . In this regard, it is noteworthy that nursing methods themselves are well structured, applying terminologies or theoretical framework well described, which were mostly (17) found in the scientific articles. This reality is the outcome of the professional category investment in research and innovations on the theme.
The methodology of Workload Indicators of Staffing Need (WISN) was also quite addressed in the selected studies, being used for the sizing of nursing 38 , physicians, speech therapists and of multidisciplinary team (tables 3 and 4). WISN is a methodology proposed by the World Health Organization for the calculation of personnel by applying time pattern measures of the activities that make up the workload and availability of each professional 7,78 .
As to Monteiro et al. 78 , the workload assessment of health professionals yields relevant information on sizing to support decisionmaking on the prevision, provision and allocation of resources in different areas.
However, among the WISN limitations, Pierantoni et al. 64 noted that it considers the workload and current productivity of professionals without taking into account schedules and restrained demand, besides not including important variables such as the perception of workers and managers and the health needs of the population. Concerning work processes, the author points out that, in multi professional and shared work, it would be impossible to standardize and individualize workloads for each professional.
In this regard, it is worth mentioning that the workload assessment appears in different degrees in the studies found in this review, including those that do not use their own method or instrument. As an example, we highlight the sizing created by Carvalho and Nascimento 71 , who propose the definition of the number of family health teams proportionally to the social vulnerability of the territory and the number of physicians, also according to the size of the Emergency Care Unit (UPA). Likewise, Cruz and Oliveira 26 suggest that the need for administrative auxiliaries follows UBS size. Thus, they understand that the workload will be proportional to the size or vulnerability, recognizing and assessing such variation in the workload as an important parameter to identify the required FTS.
A challenge put to PDFTS is to create metrics that consider the uniqueness of each location, the diversity of actions and the multiple professions; not the standardization of these measures 25, 79 . Thus, the predominance of own methodologies or models not yet labeled, containing the description of stages performed or presenting adaptations of methods consolidated in studies that include multidisciplinary teams (table 4) symbolizes also the equilibrium to rigid norms as the effort to address this challenge.
Oliveira 74 proposes and simulates the application of a multi professional team sizing model to the clinical engineering area in university hospitals, offering a check list, a calculation instrument and the reference parameters for estimating the service demand and the execution time of each activity, following the local specificities of the scope of practices.
The method proposed by Possa, Gosch and Ferla 25 approaches sizing as a continuous process that includes stages of agreement on work processes and indicators and parameters to quantify the required FTS, among others. By associating PDFTS to health care models and to participatory processes that expand GTS capacity, the authors offer a methodological innovation applicable to any health service or team, although without reporting their experiment.
Thus, the workforce projection methodologies addressed to meet future needs using demographic variables to assess the demands 58,59,65 represent a counter-hegemonic movement in relation to the methods that propose to calculate FTS only from offers already made and services already created.
Possa et al. 80 understand that PDFTS should start from the user demand and not from the supply of services, which are strongly influenced by patterns determined normatively by training and corporative institutions, which, in turn, define the limits of knowing and doing of health workers, regardless of the singularities of territories and of each health region.
In this regard, the results of this literature review show that, although being more frequent to use workload measures related to care demands as for systems that classify users according to their clinical conditions and degree of dependence on care, some FTS quantification methods aggregate other and different variables, such as: relation between number of professionals and installed capacity; opening hours of services; age of the professionals; health needs of the population; and vulnerability conditions of the territory.

Regionalization and levels of RAS care
The articulations between RAS services, the population and the health teams occur in the territory. Therefore, it is not only the space where each health unit is inserted able to be sized 25 but also where there is greater explanatory capacity of the factors that interfere in the health condition, resulting in people's needs 6 . Thus, considering the singularities of each territory and health needs of people who attend these living spaces is essential to qualify the look of those who perform PDFTS.
Regarding the location of the studies, most (51.6%) methodologies were applied in southern and southeastern states (tables 2 to 4), possibly sampling the interstate and regional disparities in the supply of professionals throughout Brazil 14, 34 .
The local scope also predominates, being PDFTS methods developed in one or more units of a health facility, with a major focus on hospital investigations, regardless of scope, what is consistent with findings of previous reviews 7, 9 . Thus, production opposes the needs of comprehensive care, which requires the integration of RAS different levels of care and the availability of multidisciplinary teams so to provide health promotion, disease prevention and health recovery 4,3 . We mostly detect PDFTS studies involving only one point or care level (71%), a predominance that can feed and reinforce the fragmented logic still carried on in SUS, focused on the biomedical and hospital-centered model. PDFTS can adopt multiple forms, that is, it can be outlined between processes mainly centered on hard technologies, focusing on standardized norms, or processes addressed to care sizing, centered on light technologies and health needs 81 . Thus, PDFTS methods embed the health care model currently applied and the way care is organized.
In this regard, the results of selected studies that identify deficits of nursing professionals can be noted while there is a surplus of nursing technicians or assistants 41,57 , unveiling that such disproportion often compromises the offered quality of care 42 . However, this unequal distribution among the subcategories that make up the nursing workforce, showing a smaller number of nurses than recommended by COFEN to hospitals 45 , corresponds to the nursing current characteristic in the Brazilian health system 39 , and not to what the regulations aim for in the future.
The example confirms Ayres' 82 claim that health care models feedback the use and ways of managing and operating health technologies, in a dialectical relation between their organization and their operation in the everyday reality. Thus, so to evaluate the FTS able to provide SUS progress, recognizing a user-centered care model, it is necessary to overcome the analysis of hospital bed structures and services offering, also observing the diversity of work processes, the complex needs of the population, the regional realities and RAS structuring 5,6,79, 83 .
Although it is mandatory to overcome the weaknesses in work management through all health regions so to comply with SUS 4 planning, it was found that only 38.7% of the selected publication mentions regionalization or RAS.
When it occurs, the mention to the subject arises mostly by introducing SUS either in the beginning of documents or in the contextualization of the problems under investigation, without defining a direct relationship with PDFTS. Just three studies directly connected PDFTS to the organization of regionalized care networks, asserting that FTS sizing is strategic for RAS 6 structuring and characterizing the workforce within the scope of health regions 21, 37 .
The organization of SUS assume a coherent relation between health planning, policies and practices 84 , as well as the construction of management models that respect their principles and drive new logics, breaking with centralizing hegemonic models focused on rigid norms 85 , which hinders the understand that RAS structure is merely bureaucratic and normative 3 . It would be essential to develop PDFTS methodologies able to contribute to GTS policies in accordance to the need of multi-professional care and to the health model organized in RAS 83 .
On the other hand, it is considered an advance to find, within the research decade, a set of publications aiming to understand rationality and evaluate possibilities for the use of WISN 64 ; to prepare patterns recommendations 38,63,70 ; to develop new methods and tools for PDFTS 49, 74 ; or even to offer courseware so that SUS managers and workers can be equipped for the PDFTS process 6 .

Final comments
This integrative review contributes to the systematization of knowledge on PDFTS published in Brazil between 2011 and 2020, although being important to mention the limitation entailed by the inclusion of texts just in Portuguese. The broad searches and the choice for not restricting the search to journals allowed for identifying and giving visibility to book chapters and other kinds of publication that describe practical experiences of actual and multiple Brazilian circumstances.
All health professions appear in the set of publications on PDFTS retrieved during the research decade, indicating an improvement. However, most of the production is dedicated to only one profession and focused on those demanding higher education. A gap is perceived as to multi-professional integration, and also as a challenge for SUS care model structuring. As in other literature reviews on this theme, nursing played the leading role, the major category among the objects and authors of the studies.
Several studies measure FTS by means of surveys on the number of professionals available or hired for work, analyzing their distribution and not properly estimating the number of necessary workers, limiting themselves to the identification and description of profiles. Amongst models that calculate the needs, most use the workload assessment as the main parameter and are limited to the application of sizing to a team or service or part of a hospital, without articulating with the singularities of each territory or RAS points, contributing more to the local management than to the management of the health system in its regional scope.
There is greater attention attributed to workload parameters related to the user clinical conditions to the detriment of other variables related to vulnerabilities and to RAS structuring scope in the territory, the latter, disregarded in the calculations, which, therefore, aids the analysis but does not actually influence the size and profile of the planned workforce. There is a scarcity of PDFTS methods that glimpse health regions under systemic condition and that include workers of all levels of care, curbing the analyses and evidencing the need to broaden the debate in this respect.
In order to overcome a PDFTS detached from SUS planning, showing low levels of workable guidelines for the structuring of regionalized networks, it is required to invest in knowledge construction and to undertake PDFTS models guided by the population health needs and by multi-professional care, aiming at the systemic integration of RAS points of attention in its regional diversity. It is also suggested that further studies be developed on PDFTS forms related to the emergency expansion efforts of FTS capacity, and on the diversity of bonds and working conditions recently affected by the emergence of COVID-19.

Collaborators
Carvalho DS (0000-0002-9223-6891)* contributed to the conception of the study; data selection, analysis and interpretation; content writing and critical review; and approval of the manuscript final version. Nascimento