High Turnover Rates in São Paulo's Primary Healthcare Units

Teresa Santos (in collaboration with Ilana Polistchuck, MD)

May 30, 2023

Although Brazil has stood out as an example of good primary healthcare (PHC), there are still concrete obstacles to the expansion of PHC in Brazil and around the world, including the high turnover rate of physicians. According to a study published in the journal PLOS ONE, physicians stay approximately 1 year and 2 months at Brazilian basic healthcare units (UBSs). According to the researchers, who evaluated more than 2000 physicians in the city of São Paulo, disparities between the healthcare units and individual characteristics, such as specialist training and professional experience, are among the factors influencing tenure.

Ivan Hossni Dias, MD, PhD, Alicia Matijasevich, MD, PhD, and Mário Scheffer, MD, all affiliated with the University of São Paulo School of Medicine, together with Giuliano Russo, DPhil, from the Queen Mary University of London, conducted a retrospective cohort study of a population of physicians using databases from three private organizations that manage the Primary Healthcare Services Human Resources Database in the city of São Paulo. They also examined data from the 2020 Brazilian Medical Demographics study. The current study included 2335 physicians who had worked or were still working in 284 UBSes in the city of São Paulo from January 1, 2016, to July 17, 2020.

The average tenure of physicians in UBSes was 14.54 ± 12.89 months. The median tenure was 10.94 months, and the maximum tenure was 54.41 months. At the end of the study, 855 (36.62%) physicians were still actively employed in PHC, while 1480 (63.38%) had terminated their employment. "Approximately half of the physicians in São Paulo appeared to have terminated their employment within approximately 11 months of their hire at a UBS, which is consistent with the findings of other studies showing that the short tenure of physicians is a global phenomenon, which may be detrimental to PHC organizations," wrote the authors.

The researchers also affirmed that most participants (50.71%) worked full time in PHC (40 hours per week); 1151 (49.29%) worked less than full time (fewer than 40 hours per week). Differences in workload by specialization were observed. Among the 1752 (75.03%) physicians without specialist training, 59% worked a full-time schedule. Among the specialists, 75% worked a part-time schedule.

According to the authors, being between the ages of 30 and 60 years at the time of being hired and living in the city of São Paulo were factors that protected against termination of contract from PHC service. Collinear to age at hire, professional experience was significant, and those who had more than 3 years of experience since graduation from medical school were at lower risk of having their contracts in PHC terminated. It is noteworthy that 71.42% of professionals had been hired within the first 5 years after graduation.

The physicians at highest risk of their contracts in the UBSes being terminated in the city of São Paulo were those who were younger than 30 years, those physicians who were newly graduated, and those with fewer than 3 years of training in the contract and with specialization not related to PHC.

On the other hand, the study found that type of specialization — family and community medicine and gynecology or obstetrics in particular — can be factors that protect against high turnover in PHC. The authors state that joint action is necessary to increase the number of family medicine specialists in PHC, as well as to give nonspecialist physicians or specialists in areas other than family medicine qualifications to work in PHC.

The study also showed evidence that differences between UBSes accounted for more than 10% of the variance in physician employment termination from PHC, although the employing organizations (hirers) were responsible for only 2.3%. According to the authors, this result suggests there are similarities in the relationship between contractual conditions and employment among PHC physicians in the city of São Paulo, regardless of the hiring organization. "This result supports the hypothesis that certain PHC service contexts and characteristics, for instance, their location in neighborhoods or districts closer to the city outskirts and with lower social indicators, are associated with higher physician turnover, which requires further study," the team writes.

According to the authors, the study revealed that of the various factors that contribute to the high turnover of PHC professionals in São Paulo, some could be changed through investment in service infrastructure and work conditions and through the implementation of teaching and human resource policies that promote "the training, career planning, and financial incentives needed for permanence in PHC."

This article was translated from the Medscape Portuguese Edition.


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