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The present study strongly highlights the high turnover of physicians in PHC services in the East Zone of São Paulo. The average time until the termination of the contract was 2.14 years, that is, the professionals remained around 2 years in the services, although some individuals who stayed longer or very short periods in the PHC services influence this average. Almost half of the professionals left PHC shortly after admission (1.17 year). In other words, after hiring a medical professional, the probability of termination of his contract in the first year is 45%. In 5 years, this probability rises to almost 90%. Thus, only 10% of all active medical workforce remained in the services after 5 years of study follow-up.
Among the individual characteristics of the physicians studied here, the homogeneity of the gender variable was noted, with a slight female predominance: 52.6% of the PHC physicians at the follow-up were women. Though alone this data does not reflect the phenomenon of feminization of medicine, the Brazilian medical literature has already reported this process [35].
Regarding the age of doctors at the time of hiring, the group studied is quite young: 55.2% were under 30 years old. Although the profession’s youth in Brazil is a trend, in the total population of doctors in the country, in this same age group (up to 29 years) are 42.6% of professionals [35]. Brazil has witnessed in the last decade the opening of many new private medical schools, including the city of São Paulo, one of them Santa Marcelina, The increased supply of newly graduated doctors, combined with the large availability of vacancies in the municipality’s PHC, could lead to an even younger profile of the occupants of these jobs. Direct entry into the labor market, either because of difficulty in accessing a specialty residency, or the desire for more immediate financial gains (need to pay off public or private educational debts assumed at undergraduate level), is a phenomenon that needs to improve considering its possible impact not only on the longevity in PHC services, but also on the quality of care provided to the population [35,36,37,38,39,40,41,42],
Younger individuals, ≤25 years, averaged 1.4 years in PHC services, while those aged 30 and over remained for 2.7 years. However, when adjusting the final model, age was not significant as a disengagement factor. Collinear to age, the time since graduation was relevant, with statistical significance, in the dismissal of doctors, and those graduated less than 2 years spent less time in PHC services, with a mean of 1.7 years.
Most of the physicians (78%) had a 40-h workweek, a workload that reached 89% of the FHS doctors. The workload, as shown, is a contributing factor to the TEC. Doctors on a 40-h weekly basis had a significantly higher occurrence of TEC. Previously exclusively set at 40 h per week by federal determination [48], the journey of doctors in the PHC and FHS gained other possible configurations over the years, being allowed a workload of 20 or 30 h per week as of 2011 [49].
As with the full 40-h workday, the higher starting salary remained significant after adjustment as a factor of lower severance. Two variables, the 40-h workday and the highest salary, are related, since salaries are largely proportional to the hours hired or worked.
PHC Santa Marcelina has already adopted a salary additions policy for districts in the East Zone that have greater difficulty in attracting doctors, such as Itaim, Guaianases and Tiradentes, due to the great distance of these regions to the city center. The practice of different wages within the same institution is a sensitive theme that runs into labor laws and can lead to greater wage inequalities between doctors and other professionals equally essential to PHC [50]. It has been shown that salary is a factor of attraction in PHC [23] but is insufficient to guarantee its permanence in medium and long term [22].
It was found in the study that the vast majority of doctors (88.1%), upon joining the PHC service, had no medical specialty, i.e. had not completed a residency program or obtained the title of specialist by the Medical Society. There is usually no requirement for any specialty title to occupy the position of physician in PHC services. Job selection and hiring processes refer to “general practitioners”, understood as the professional with a general medical background, i.e., the doctor with a completed degree and registration in the regional medical council.
The lack of specialization at the time of admission could be explained by the low average age of the physicians in this study. That is, for many, there was still not enough time to complete the specialization. It is also known that there are not enough Medical Residency positions for all medical graduates; paradoxically, there is a low demand for Family and Community Medicine Residency vacancies, a specialty that has insufficient specialists to supply the jobs of doctors at PHC. Some municipalities in southern Brazil, such as Florianopolis, exception to the rule, insert in the contracting notices for FHS, the residency criterion or specialist title, aiming at a higher qualification of PHC human resources [51].
Among the findings of the study, 11.5% of physicians (who were not specialists at the time of admission) completed a residency within 3 years after the termination of contract in the PHC Santa Marcelina. This was a factor of strong impact on TEC, indicating that for this group of physicians, work in PHC may have been merely a transition between the end of graduation and beginning of residency, often in non-PHC specialties.
The percentage of specialists among admission (only 12%) increased significantly among those who were discharged; 45% of physicians who left PHC services throughout the study had a specialist title until 2016, the last year of follow-up. After leaving PHC, they specialized mainly in Gynecology and Obstetrics (13.2%), Pediatrics (12.9%), Family and Community Medicine (12.4%) and Clinical Medicine (11.0%). Although specialties are all suitable and relevant to PHC, it is noteworthy that Family and Community Medicine was not the priority choice.
Therefore, it should be a matter of concern for the human resources policies in PHC the entry of large numbers of young doctors, recent graduates, without specialization and with post-retirement professional choices unrelated to work and PHC goals.
Although the number of doctors in Brazil has been growing exponentially, increasing 3.5 times more than the population between 1980 and 2010 [52], the persistent increase in the number of doctors did not benefit homogeneously all Brazilian citizens [42]. The city of São Paulo had 59,934 doctors [35] in professional activity in 2018, registered with the Regional Council of Medicine (CRM), a ratio of 4.98 doctors per 1000 inhabitants, compared to capitals with the highest concentrations of doctors in the world and our study showed lack of these professionals in the periphery of the same city. The “Mais Médicos” federal Program (More Doctors) created in 2013 [53], and its successor, in 2019, the “Médicos pelo Brasil” (Doctors for Brazil) Program [54] have given rise to important policy debates but still haven’t resulted in a full coverage of PHC.
The findings of the present study point to concrete obstacles to the expansion of PHC, whose proportion of population coverage is insufficient, even in the city of São Paulo, since it does not reach 50% in the region studied. Even when overcome, the difficulty of hiring doctors in PHC is compounded by the high turnover of those who enter the services. Leaving after a short-term stay constantly deflects FHS teams or leaves open jobs at UBSs, a phenomenon that requires extra efforts and replacement costs that are not always successful.
Some of the attributes of PHC are compromised with this dynamic, such as the ability to solve the vast majority of the population’s health problems and continuousness, which presupposes continuity of care, building bonds and accountability between professionals and users over time, permanently and consistently.
Studies have also shown that high staff turnover at PHC has a financial impact that includes the actual cost of entering and leaving staff, the cost of temporary replacements, as well as the cost of training, immersion activities, and alignment with care lines and the organization of services [55]. Overworking remaining professionals and breaking ties among the PHC team are other possible effects of physician turnover. On the population side, as the services most affected are those in regions of greatest social vulnerability, the vicious cycle of the lowest care associated with the worst health indicators seems to support a feedback system [56].
The methodological choice of physician dismissal measurement through the survival curve allowed the use of all study participants, regardless of the date of entry. Such methodology has been used in other countries [57,58,59,60] and in Australia, survival curves are essential as a methodology to track the effectiveness of national health manpower policies [58]. Retention in both cases (before and after retention policies) was higher than that observed in this study. Russell et al. [59] were able to demonstrate, through survival analysis techniques, the influence of factors associated with geographic location and population size on the retention phenomenon of physicians.
In Brazil, literature from the last decade has highlighted the inequalities in the supply and distribution of doctors, as well as the official policies for the establishment and provision of doctors implemented throughout the history of the health system. The high turnover of physicians in PHC services in Brazil is associated with multiple factors that generate professional dissatisfaction, such as inadequate working conditions, excessive workload, low pay and lack of job, career and salary plans [61,62,63,64,65]. The reasons that may favor the permanence are the identification with the PHC, the professional vocation and the perspective of serving the community [25, 37, 44, 51].
Resistance factors to exclusive dedication or permanence in a single workplace in PHC must also be considered as the characteristics of the medical profession in Brazil, are defined by the double public and private practice [45] and by multiplicity of work relationships (almost half of doctors have three or more jobs), long working hours (two thirds of doctors work more than 40 h per week), working shifts (45% make at least one shift per week), beyond the prospect of higher incomes that is usually only achieved through accumulation of jobs and activities. According to the Medical Demography in Brazil [66], the average physician’s workload is more than 50 h per week, and almost a third of professionals work more than 60 h per week. Doctors work, on average, in three different jobs, with more than 30% accumulating four or more contracts. The professional usually occupies more than one job in UHS, often hired by more than one employer in the same municipal network. Most doctors working in the public sector share their work schedule with a private practice or practice in the private sector. It should be considered that in the city of São Paulo there is a large and diverse private network that employs part of the doctors who simultaneously work for the UHS [45, 66].
Throughout the history of the Brazilian health system, many governments have attempted to ensure the supply of doctors in PHC and other levels of care [67,68,69,70], including the Rondon Project, the Internationalization of Health Work (PITS), the Program to Support the Training of Specialist Physicians in Strategic Areas (Pro-Residency), the Appreciation Program for Primary Care Professionals (PROVAB). The two most recent federal medical provision programs, “Mais Médicos” and “Médicos pelo Brasil” [53, 54], did not use in their conceptions and legal frameworks evidence on physician turnover and permanence in PHC, but both set criteria for municipalities’ eligibility that would benefit from the programs [39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54, 66].
A strength of the study was the possibility of the integration of the human resources department’s administrative database of the medical contracting organization in PHC with the most comprehensive study database, Medical Demography in Brazil, which allowed for an unprecedented approach to information and characteristics of physicians not reached by the isolated databases. This permitted the use of a large number of physicians over a long time period. However, this study has limitations, the main one being the limit range of findings, restricted to the available data and the variables selected for analysis, and the use of secondary data only, always subject to incompleteness of information and lack of systematization of records such as the authorization of doing less than 40 h/week was approved in 2011, 5 years after the study beginning that could be a confounding factor not measured thoroughly. This study could be extended to all São Paulo PHC and could be an interesting observatory for prospective cohort. A qualitative study could amplify the range of variables.
The turnover of doctors in PHC, is multifactorial. Various individual characteristics of physicians, service administrators and employers, as well as geographical, professional, financial and educational factors, are associated with retention of physicians in PHC [71,72,73,74,75,76]. Higher turnover has also been related to job dissatisfaction, conflicts between work and family care [77], as well as stress and burnout in a professional setting [78, 79].
Therefore, there are several research fronts and quantitative and qualitative methodologies that need to be considered for the systemic and complete approach to the problem. In the case studied, information related to physicians’ personal choices, perception of security and violence in the East Zone, and opinion about the management institution’s profile and conduct, just to name three examples of topics not reached by secondary data, would be relevant to a better understanding of physicians’ withdrawal and permanence factors in PHC services.
