Inequalities in Technical
Brazilian Health Workforce
August/2009
Alexandra AlmeidaMônica VieiraArlinda MorenoMárcio Candeias
2
Outline
1. Who We Are2. The Research Project3. Data Base4. The Health Sector5. Some Brazilian Health Workforce Idiosyncrasies6. The Problem7. The Objective of this Study8. A Statistical Help9. Reading the Model10. Results and Conclusions11. Further Work
3
Who We Are
Brazilian Ministry of Health
Oswaldo Cruz Foundation
Polytechnic Health School Joaquim Venâncio
Work Laboratory and Health Care
Professional Education
Brazilian Health Technicians Observatory
GOAL: Produce and share knowledge about the technical Brazilian workers aiming the health workforce development.
4
The Research Project
Works in the construction of occupational categories that represents the general Brazilian Health sector; identication of the technical workforce analysing the qualification, trends, and the characteristics of these workers.
However...
How can we infer about the technicians workers in Brazilian Health Sector?
5
The Research Project
‒ The first (and macro) approach to study this workers was done considering the AMS (Medical-Sanitary Assistance)
Survey produced by IBGE (Brazilian Institute of Geography and Statistics).
Investigates all the health institutions existing in the country which provide individual or collective health assistance services.
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The Research Project
‒ The AMS exploratory analyses brings some interesting information:
The high school jobs are concentrated in Brazil southeast region,
The elementary jobs are concentrated in Brazil northeast region.
A natural extension is studying the health
workers, instead of establishments.
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Data Base
PNAD: National Household Sample Survey
Produced by IBGE (Brazilian Institute of Geography and Statistics).
Represents a valuable instrument to the evaluation of the socio-economic and demographic reality in the country.
Brings general attributes (self-declared) of the Brazilian population like
Occupation Schooling Labor details …
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The Health Sector
Brazilian Health
Occupations
AdministrativeMedical/Hospital
EquipmentSupport
Specific Health
Other
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Some Brazilian Health Workforce Idiosyncrasies
Gender Distribution (%)
38.6
25.1
43.1
58.9
23.0
61.4
74.9
56.9
41.1
77.0
0 25 50 75 100
Other Occupations
Especif ic HealthOccupations
Support Occupations
Medical/HospitalEquipment
Occupations
AdministrativeOccupations
Male Female
Job Sector Distribution (%)
70.9
44.6
59.4
73.3
74.9
29.1
55.4
40.6
26.7
25.1
0 25 50 75 100
Other Occupations
Especif ic HealthOccupations
Support Occupations
Medical/HospitalEquipment
Occupations
AdministrativeOccupations
Private Public
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Some Brazilian Health Workforce Idiosyncrasies
Worked Hours per Week (%)
1.1
22.0
54.8
11.7 10.4
0.5
21.9
46.9
16.1 14.6
2.1
20.4
43.8
20.4
13.4
2.8
29.5
34.8
10.9
22.0
1.1
17.9
46.7
21.2
13.0
0
20
40
60
80
100
Less than 14 horas 15 to 39 hours 40 to 44 hours 45 to 48 hours More than 49 hours
Administrative Occupations Medical/Hospital Equipment OccupationsSupport Occupations Especific Health OccupationsOther Occupations
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The Problem
‒ The variable occupation was constructed based in the Brazilian Occupations Classification (CBO), a Brazilian adaptation to the International Standard Classification of Occupations (ISCO).
‒ Some PNAD occupations in health: Nurses professionals Nursing technicians Chemist Chemical Technicians Biologist and related (???)
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The Objective of this Study
Identify the technicians health workers
1. Groupping occupations by similarities
2. Selecting pairs of occupations where the tecnicians and professionals are not fuzzy.
3. Modelling (statistically) the characteristics that delimits the workers as technicians and professionals.
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A Statistical Help
‒ We constructed occupations clusters for the “Especific Health Occupation” group, and select the pairs:
Chemist and related technicians Pharmaceutic and related technicians Nursing and related technicians Phisiotherapy and related technicians Odontologist and related technicians
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A Statistical Help
Pairs’ Descriptive Statistics
Professionals Technicians
Gender Male 179 49.7% 181 50.3% Female 445 30.3% 1023 69.7% Schooling Elementary School 5 10.6% 42 89.4% High School 20 2.3% 832 97.7% Graduate 509 78.4% 140 21.6% Master or Doctor 28 96.6% 1 3.4% Job Sector Private 175 24.5% 540 75.5% Public 169 22.5% 582 77.5%
Less than 14 hours 21 51.2% 20 48.8% 15 to 39 hours 181 31.7% 390 68.3% 40 to 44 hours 224 34.7% 421 65.3% 45 to 48 hours 60 26.9% 163 73.1%
Worked HoursPer Week
49 hours or more 137 39.5% 210 60.5%
Professionals Technicians
2030
4050
6070
Age
Professionals Technicians
020
0040
0060
0080
00
Income
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A Statistical Help
‒ In order to model/predict the relationship between workers characteristics to their actual worker position we use the bernoulli model,
‒ The bernoulli probability function is expressed as:
where π is the probability of success, y corresponds to success or failure.
1,0;)1()( 1 yyYP yy
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A Statistical Help
‒ The logit function was chosen by the AIC and BIC criteria.
‒ The variables age, gender and worked hours per week were not statistically significant, and do not belong to the final model.
In gray, the basal category
Coefficients Estimate Std. Error z value Pr(>|z|)
Intercept 2.0349 0.5409 3.7620 0.0002
Schooling: Elementary School - - - -
Schooling: High School 1.8733 0.5894 3.1780 0.0015
Schooling: Graduate -2.5597 0.5550 -4.6120 0.0000
Schooling: Master or Doctor -4.3159 1.1795 -3.6590 0.0003
Income -0.0004 0.0001 -3.2010 0.0014
Job Sector: Private - - - -
Job Sector: Public 0.6502 0.2054 3.1660 0.0015
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A Statistical Help
Goodness-of-Fit
Hosmer and Lemeshow Test
Observed Expected Observed Expected1 102 104.25 27 24.75 1292 97 88.46 30 38.54 1273 71 74.71 53 49.29 1244 17 21.46 107 102.54 1245 3 3.07 114 113.93 1176 3 3.04 122 121.96 1257 2 2.82 123 122.18 1258 5 2.12 129 131.88 1349 1 1.65 124 123.35 125
10 2 1.41 117 117.59 119
Professionals TechniciansTotal
28
10
1
22 ~
/1
)(
i iii
iiHL nEE
EOG
Where:ni is the number of observations in the ith groupOi is the observed number of cases in the ith groupEi is the expected number of cases in the ith group
P-value: 31.78%
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A Statistical Help
Residual Analysis
Studentized Residuals
Studentized Residuals
Fre
qu
en
cy
-3 -2 -1 0 1 2 3
02
00
40
06
00
80
0
-3 -2 -1 0 1 2 3
-3-2
-10
12
3
Normal Q-Q Plot
Standard Normal Quantile
De
via
nce
Normal Q-Q PlotNormal Q-Q PlotNormal Q-Q Plot
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A Statistical Help
‒ In order to evaluate the predictive power, we calculate the confusion matrix, and:
Total rate of correct classification: 88.3% Percentage of professionals well classified: 93.1% Proportion of technicians well classified is 86.8%.
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Reading the Model
Scholling‒ Workers with high school as higher level have 6 times
more chances to be technicians than those who have just the elementary school
‒ The graduated workers have 13 times more chances to be a professional
‒ Master/doctor workers are 75 times more likely to be professionals than those with elementary school.
Job Sector‒ The workers in public institutions have approximately 2
times more chances to occupy a technical position.
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Results and Conclusions
‒ Imbalances: 14% of the workers in technicians occupation are graduated or
have a master/doctor;
66% of the workers in technicians occupations work more than 40 hours per week;
‒ Study Benefits: A right work insertion based on the schooling has a larger impact
in public health sector. The multiple work links dimishes the income impact (estimated
coefficient: -0.0004); The model allow us to identify the technicians with
graduation, master/doctor Estimating the Brazilian health technical workforce amount.
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Further Work
‒ Extend the cluster analysis to the others 4 health occupation groups (managers, medical/hospital equipment, support and others),
‒ Sophisticate the model to cover all health occupations groups.
‒ Explore all the available years of the survey, understanding the trend of the qualification and work insertion of this workforce.
Inequalities in Technical Brazilian Health Workforce
ISI, August/2009
Alexandra AlmeidaMônica VieiraArlinda MorenoMárcio Candeias
Thanks!!!Polytechnic Health School Joaquim Venâncio:
www.epsjv.fiocruz.br
International Network of Health Technicians Eucation:
www.rets.epsjv.fiocruz.br