Inequality in the middle of a crisis: an analysis of health workers during the COVID-19 pandemic from the profession, race, and gender perspectives. / Desigualdade em meio à crise: uma análise dos profissionais de saúde que atuam na pandemia de COVID-19 a partir das perspectivas de profissão, raça e gênero.

Studies show that people in vulnerable conditions and some social groups such as women and black people have suffered more intensely from the COVID-19 pandemic impacts. This expression of inequality also manifests itself among healthcare workers, with greater exposure of some specific groups. This paper analyzes the effect of COVID-19 on health care workers and the working conditions in the Brazilian public health system, analyzed from professional, gender, and race perspectives. Data were collected from an online survey of 1,829 health workers conducted in March 2021. Indeed, we identified inequalities in health workers' experiences during the health crisis generated by COVID-19, which are marked by the profession of each worker and are traversed by their gender and race traits.

Estudos mostram que pessoas em condições de vulnerabilidade têm sofrido de forma mais intensa os impactos da pandemia de COVID-19, assim como alguns grupos sociais, como mulheres e negros. Essa expressão de desigualdade também se manifesta entre os trabalhadores da saúde, com maior exposição de alguns grupos específicos. Este artigo analisa a incidência da COVID-19 sobre os trabalhadores da saúde a partir das perspectivas de profissão, gênero e raça. Os dados foram coletados por uma survey online com 1.829 trabalhadores da saúde, realizada no mês de março de 2021. Encontramos que, efetivamente, há desigualdades nas experiências dos trabalhadores da saúde durante a crise sanitária gerada pela COVID-19. Essas desigualdades estão marcadas pela profissão de cada trabalhador e são atravessadas por suas características de gênero e raça.

Violence against healthcare workers in the middle of a global health crisis: what is it about policy and what to learn from international comparison?

Introduction: Violence against healthcare workers is a global health problem threatening healthcare workforce retention and health system resilience in a fragile post-COVID 'normalisation' period. In this perspective article, we argue that violence against healthcare workers must be made a greater priority. Our novel contribution to the debate is a comparative health system and policy approach. Methods: We have chosen a most different systems comparative approach concerning the epidemiological, political, and geographic contexts. Brazil (under the Bolsonaro government) and the United Kingdom (under the Johnson government) serve as examples of countries that were strongly hit by the pandemic in epidemiological terms while also displaying policy failures. New Zealand and Germany represent the opposite. A rapid assessment was undertaken based on secondary sources and country expertise. Results: We found similar problems across countries. A global crisis makes healthcare workers vulnerable to violence. Furthermore, insufficient data and monitoring hamper effective prevention, and lack of attention may threaten women, the nursing profession, and migrant/minority groups the most. There were also relevant differences. No clear health system pattern can be identified. At the same time, professional associations and partly the media are strong policy actors against violence. Conclusion: In all countries, muchmore involvement from political leadership is needed. In addition, attention to the political dimension and all forms of violence are essential.

Early Response to COVID-19 in Brazil: The Impact of a Targeted Approach to Suspected Cases and on Epidemiologic Surveillance Efforts

Background SARS-CoV-2 entered Brazil before travel restrictions and border closures were imposed. This study reports characteristics of suspected and confirmed COVID-19 cases among symptomatic international travelers in Brazil and their contacts. Methods We analyzed the REDCap platform developed by the Brazilian Ministry of Health to notify and investigate suspect cases of COVID-19 from January 1 to March 20, 2020. We analyzed the impact of Brazil's targeted approach to suspected cases from specific countries on epidemiologic surveillance efforts during the early stages of the COVID-19 pandemic. Results Based on molecular RT-PCR tests, there were 217 (4.2%) confirmed, 1,030 (20.1%) unconfirmed, 722 (14.1%) suspected, and 3,157 (61.6%) non-investigated cases among travelers returning from countries included in the alert list for surveillance, as defined by the Ministry of Health. Among those who traveled to countries not included in the alert list (n=3,372), there were 66 (2.0%) confirmed, 845 (25.3%) unconfirmed, 521 (15.6%) suspected, and 1,914 (57.2%) non-investigated cases. A comparison of the characteristics of confirmed cases returning from alert and non-alert countries did not reveal a statistically significant difference in symptoms. Almost half of the hospitalized travelers with known travel dates and hospitalization status (53.6%) were inbound from countries not included in the alert list and RT-PCR tests were reported for only 30.5%. Conclusions Policies adopted at entry points to contain the introduction of SARS-CoV-2 in Brazil were not ideal. An analysis of the early response shows that surveillance of travelers, including testing strategies, data standards, and reporting systems, was insufficient.

SDG5 "Gender Equality" and the COVID-19 pandemic: A rapid assessment of health system responses in selected upper-middle and high-income countries.

Introduction: The COVID-19 pandemic disrupted healthcare and societies, exacerbating existing inequalities for women and girls across every sphere. Our study explores health system responses to gender equality goals during the COVID-19 pandemic and inclusion in future policies. Methods: We apply a qualitative comparative approach, drawing on secondary sources and expert information; the data was collected from March-July 2022. Australia, Brazil, Germany, the United Kingdom, and the USA were selected, reflecting upper-middle and high-income countries with established public health and gender policies but different types of healthcare systems and epidemiological and geo-political conditions. Three sub-goals of SDG5 were analyzed: maternity care/reproductive health, gender-based violence, and gender equality/women's leadership. Results: We found similar trends across countries. Pandemic policies strongly cut into women's health, constrained prevention and support services, and weakened reproductive rights, while essential maternity care services were kept open. Intersecting gender inequalities were reinforced, sexual violence increased and women's leadership was weak. All healthcare systems failed to protect women's health and essential public health targets. Yet there were relevant differences in the responses to increased violence and reproductive rights, ranging from some support measures in Australia to an abortion ban in the US. Conclusions: Our study highlights a need for revising pandemic policies through a feminist lens.

Comparing Health Workforce Policy during a Major Global Health Crisis: A Critical Conceptual Debate and International Empirical Investigation.

BACKGROUND: The health workforce is central to healthcare systems and population health, but marginal in comparative health policy. This study aims to highlight the crucial relevance of the health workforce and contribute comparative evidence to help improve the protection of healthcare workers and prevention of inequalities during a major public health crisis. METHODS: Our integrated governance framework considers system, sector, organizational and socio-cultural dimensions of health workforce policy. The COVID-19 pandemic serves as the policy field and Brazil, Canada, Italy, and Germany as illustrative cases. We draw on secondary sources (literature, document analysis, public statistics, reports) and country expert information with a focus on the first COVID-19 waves until the summer of 2021. RESULTS: Our comparative investigation illustrates the benefits of a multi-level governance approach beyond health system typologies. In the selected countries, we found similar problems and governance gaps concerning increased workplace stress, lack of mental health support, and gender and racial inequalities. Health policy across countries failed to adequately respond to the needs of HCWs, thus exacerbating inequalities during a major global health crisis. CONCLUSIONS: Comparative health workforce policy research may contribute new knowledge to improve health system resilience and population health during a crisis.

Women and working in healthcare during the Covid-19 pandemic in Brazil: bullying of colleagues.

BACKGROUND: Based on a feminist approach, we analyzed the experiences of workplace bullying suffered by women front-line healthcare professionals dealing with the Covid-19 pandemic. We start from studies that show that women make up 70% of the global health workforce, 85% in the area of nursing, and 90% in the case of social care workers. An unequivocal need thus exists to address gender issues regarding the composition of the labor force in the health area. The pandemic has aggravated recurring problems involving healthcare professionals at the various caregiving levels, such as mental harassment (bullying) and its effects on mental health. METHODS: Data were gathered from an online survey of a convenience (non-probability) sample composed of 1,430 volunteer respondents, all women that work in the public health system in Brazil. The analyses and discussions involved the responses to a questionnaire containing 12 closed-ended questions and one open-ended question. RESULTS: The results revealed a context of workplace bullying aggravated by precarious material, institutional and organizational conditions in the area of health services against the backdrop of the Covid-19 pandemic in Brazil. This context has variously led to aggression, isolation, heavy workloads, and invasion of privacy, humiliation, persecution and fear as it was possible to see, mainly, in the answers to the study's open-ended question. This situation degrades both work relations and the integrity of the healthcare professionals who work on the front line to treat Covid-19 cases. CONCLUSION: We conclude that bullying is a psychosocial phenomenon that heightens the oppression and subordination still experienced by women in the contemporary context, but with new hues in a scenario of frontline response to Covid-19.

Gender and Race on the Frontline: Experiences of Health Workers in Brazil during the COVID-19 Pandemic.

Studies on the differential effects of health emergencies have largely overlooked women health workers. Whilst the literature has shown the impact of Coronavirus disease-19 (COVID-19) on women and on healthcare workers, little research has considered the gendered effects of the health workforce. This article analyses the impact of COVID-19 on healthcare workers and working conditions in Brazil's public healthcare system, through consideration of gendered and racialized understandings of care and work. Data were taken from an online survey of 1,263 health workers, undertaken between September and October 2020, disaggregated by sex and by race in order to understand health workers' experiences of the pandemic in one of the countries most significantly affected by the crisis.

The impact of the COVID-19 pandemic in the frontline health workforce: Perceptions of vulnerability of Brazil's community health workers.

The COVID-19 pandemic has resulted in calls for an increased integration of community health workers (CHWs) into the health system response. Historically, CHWs can play an important role in ensuring the sustainability of health policy implementation - by addressing social determinants of health and maintaining care for ongoing health problems. Their frontline work, with close contact to populations, places CHWs in a position of increased vulnerability to becoming infected and to being the target of abuse and violence. These vulnerabilities compound underlying problems faced by CHWs, who often come from poor backgrounds, are insufficiently paid and receive inadequate training. Speaking to a scarcity of studies on how CHWs are impacted by the pandemic, this paper conducts a systematic study of CHWs in Brazil. Based on quantitative and qualitative data collected during June and July 2020, it considers perceptions and experiences of CHWs, comparing them with other health professionals. We study the extent to which the pandemic added to existing vulnerabilities and created new problems and imbalances in the work of CHWs. We conclude that COVID-19 led to a deterioration of the working conditions of CHWs, of their relations with other health professionals, and of their ability to carry out their essential work in the public health system.

Working conditions and perceptions of nursing professionals who work to cope with covid-19 in Brazil / Condições de trabalho e percepções de profissionais de enfermagem que atuam no enfrentamento à covid-19 no Brasil

Resumo Diante da importância do trabalho de Enfermagem no combate a epidemias e dos desafios impostos pela covid-19 ao exercício da profissão, o objetivo deste artigo é analisar as condições de trabalho e as percepções das profissionais de Enfermagem sobre sua atuação no contexto da pandemia de covid-19 no Brasil. Para tanto, realizamos uma pesquisa de caráter exploratório, a partir de um questionário online, aplicado entre 15 de junho e 1º de julho de 2020, respondido por 445 profissionais. Realizamos análise qualitativa, fundamentada na análise de conteúdo proposta por Bardin e Saldaña. No campo das sensações, os relatos das profissionais evidenciam medo, aumento da irritabilidade, sobrecarga de trabalho, tristeza e solidão. A pandemia da covid-19 alterou os processos de trabalho e a organização dos serviços, influenciando no dimensionamento do quantitativo de profissionais, na jornada de trabalho e na modalidade de execução, além de demandar maior vigilância quanto às medidas de prevenção e contágio. As mudanças impactaram no tempo disponibilizado para atendimento, na interação entre profissionais e usuários, e prejudicou a comunicação. A relevância do trabalho de Enfermagem junto às equipes de saúde no enfrentamento à covid-19 no Brasil reforça a necessidade de adoção de medidas eficazes de proteção e preservação da saúde física e mental dessas profissionais.

Abstract Before the importance of nursing in fighting epidemics and the challenges imposed on the exercise of the profession by COVID-19, this paper aims to analyze the working conditions and perceptions of nursing professionals regarding their performance in the context of the COVID-19 pandemic in Brazil. This exploratory research consisted of data collected through an online survey answered by 445 nursing professionals between June 15th and July 1st, 2020. Data underwent a qualitative content analysis in the light of the propositions of Bardin and Saldaña. In the field of sensations, the professionals' reports show fear, increased irritability, work overload, sadness, and loneliness. Besides demanding greater vigilance regarding preventive measures to reduce contagion, the COVID-19 pandemic changed the work processes and services organization, influencing the quantitative dimensioning of professionals, working hours, and execution mode. Moreover, these changes impacted the time available for care and the interaction between professionals and users. The relevance of nursing work and health teams in confronting COVID-19 in Brazil reinforces the need for effective measures aimed at protecting and preserving these professionals' physical and mental health.

The vulnerabilities of the Brazilian health workforce during health emergencies: Analysing personal feelings, access to resources and work dynamics during the COVID-19 pandemic.

Public health emergencies are a test of resilience for health systems, which depend on health workforces that are well managed and cared for. The COVID-19 pandemic exposed the weakness of many health systems in preparing their health workforces. The crisis also exacerbated the unequal conditions between different professions, an issue that is still understudied in the workforce literature. This paper analyzes the consequences of the COVID-19 pandemic for different health professionals, considering the ways in which Brazil's the health system does or does not protect them. We also analyse the role of pre-existing inequalities between different professions and social groups within the workforce in shaping their different experiences of the pandemic. We present data comparing the perceptions of different health professionals facing the pandemic in Brazil: physicians, nurses, and community health workers. Data were collected in an online survey in Brazil with 1630 health care workers between June 15th and July 1st. Findings suggest that none of the professions felt well prepared to work under emergencies. However, differences relating to professional background were exacerbated during the pandemic, creating unequal conditions for different health workers. These inequalities may pose new challenges for the post-pandemic scenario.

COVID-19 and health promotion in Brazil: community health workers between vulnerability and resistance.

Health promotion in Brazil relies on community health workers (CHWs), frontline providers linking the health system with vulnerable groups. Brazilian CHWs are overwhelmingly women from poor backgrounds, with precarious and sometimes hazardous working conditions, as well as fragmented and unsystematic training. This paper evaluates how the COVID-19 pandemic exacerbated pre-existing vulnerabilities of CHWs (pertaining to low salary, precarious and hazardous working conditions and inadequate training) and created new ones, with a profound impact on their ability to carry out health promotion activities. Drawing on testimonials of dozens of CHWs and online discussions promoted by their unions, the paper reveals that during the pandemic CHWs were asked to continue their work without adequate training and protective equipment, thus exposing themselves to the risk of infection. It further shows how the pandemic rendered dangerous the close interaction with patients that is at the heart of their health promotion role. Nonetheless, CHWs sought to adapt their work. In the absence of leadership and coordination on the part of the federal government, CHWs mobilized different forms of resistance at the national and individual levels. Despite this, COVID-19 contributed to a trajectory of erosion of health promotion in Brazil. Findings from this case signal the difficulties for health promotion in low- and middle-income countries relying on CHWs to bridge the health system and vulnerable users.

Working through the fog of a pandemic: Street-level policy entrepreneurship in times of crises.

Imposing significant challenges for both street-level implementation and policy (re)design, crises alter the environment for street-level policy entrepreneurship (SLPE), wherein street-level bureaucrats engage in policy formulation processes to secure future policy outcomes. Nevertheless, like street-level implementation in general, SLPE is studied during ordinary times but rarely during crises. Focusing on community-health workers in Brazil during the Covid-19 crisis uncovered a defensive motivation for SLPE, which aimed to legitimize community healthcare as an integral part of pandemic treatment, reforming the government's hitherto neglectful approach to community health services. Moreover, the continuing crisis created an unusually prolonged window of opportunity for securing community healthcare provision. By utilizing collective efforts and drawing on powerful politicians' mobilization, SLPE during crisis shares similarities with, yet differs from, SLPE during ordinary times, while further closing the interstices between local, professional, and political perspectives in the formulation of policy decisions.

When informal work and poor work conditions backfire and fuel the COVID-19 pandemic: Why we should listen to the lessons from Latin America.

Latin America is among the regions with the highest incidence of COVID-19 where the pandemic is creating a humanitarian crisis. In this Commentary we aim to reveal underlying problems of this crisis, that may be an underestimated global driver of the pandemic and a serious risk to health and healthcare systems. We set the focus on informal work and related poorly regulated sub-contracting which create poor work conditions as one dimension of the social determinants of health. We use the examples of Germany and Brazil, as opposite sides geographically and concerning the pandemic, to highlight a need for greater attention to these risks and for systematic inclusion in health systems resilience. In both countries, informal work may turn into hot spots of COVID-19, thus reinforcing social inequalities on a grand scale both nationally and globally. Our two contrasting country cases thus reveal a global threat that should be treated as such. There is much to learn for Europe and the world from Brazil and Latin America on what happens when informal labour and poor work environments backfire during the COVID-19 pandemic. We should listen carefully to these lessons.

Street-level bureaucracy in the pandemic: the perception of frontline social workers on policy implementation

The COVID-19 pandemic highlighted the strategic role of social care policy to minimize the effects of this health crisis and its consequences on the poorest and most vulnerable population. This article analyzes the perception of street-level bureaucrats in the Brazilian social care network on how the pandemic has affected their performance and professional routine. The research was based on a survey, consultations with representatives of municipal social care services, and analysis of government regulations. The results show that social workers feel unprotected and unable to provide adequate responses to the pandemic's increasing and urgent demands, revealing a lack of institutional support to act appropriately. The professionals also reported substantial changes in their working dynamics, particularly in their relationship with the attended population, one of the main pillars of the Brazilian social care network. These elements directly affect the provision of social care services and their potential to combat the adverse effects of the crisis. Resumen La pandemia de COVID-19 destacó el papel estratégico de la política de atención social para minimizar los efectos de esta crisis de salud y de sus consecuencias en la población más pobre y vulnerable. A partir de este entendimiento, este artículo analiza la percepción de los burócratas a nivel de calle en la red de atención social brasileña en relación a cómo la pandemia ha afectado su desempeño y su rutina profesional. Con base en una encuesta, en consultas con representantes de los servicios municipales de atención social y regulaciones gubernamentales, la investigación ha identificado que, en la pandemia, estos trabajadores se sienten desprotegidos e incapaces de dar respuestas adecuadas a las crecientes y urgentes demandas, además de reportar cambios sustanciales en su dinámica de trabajo, incluyendo uno de sus principales pilares de actuación, el vínculo establecido con los usuarios del servicio. Al mismo tiempo, carecen de apoyo institucional para actuar con seguridad. Estos elementos afectan directamente la prestación de servicios de atención social y su potencial para combatir los efectos adversos de la crisis. Resumo A pandemia da COVID-19 ressaltou o papel estratégico da política de assistência social para minimizar os efeitos desta crise de saúde e de suas consequências sobre a população mais pobre e vulnerável. A partir desse entendimento, este artigo analisa a percepção de burocratas de nível de rua da rede socioassistencial brasileira sobre como a pandemia tem afetado sua atuação e seu cotidiano profissional. Com base em um survey, em consultas com representantes de serviços socioassistenciais municipais e em regulações governamentais, a pesquisa identificou que, na pandemia, esses trabalhadores se sentem desprotegidos e pouco capazes de dar respostas adequadas às demandas cada vez maiores e urgentes, além de relatarem mudanças substanciais nas suas dinâmicas de trabalho, incluindo um dos seus principais pilares de atuação, o vínculo estabelecido com os usuários dos serviços. Simultaneamente, sentem falta de apoio institucional para atuar com segurança. Esses elementos afetam diretamente a prestação dos serviços socioassistenciais e seu potencial de combater os efeitos adversos da crise.

How COVID-19 Has Affected Frontline Workers in Brazil: A Comparative Analysis of Nurses and Community Health Workers

The need to respond to the COVID-19 pandemic has created challenges for services delivered by frontline workers (FLW). This paper analyzes how the Brazilian government regulated the reorganization of Primary Health Care (PHC) and how FLW responded to these initiatives, comparing the roles played by nurses and community health workers. Given the multilevel health system, it was expected that the high level of ambiguity would stimulate innovations. However, data show that the ambiguity created different situations for each profession. While nurses were able to adapt their work and act with more autonomy, CHW lost their role in the policy.

Street-level bureaucracy in the pandemic: the perception of frontline social workers on policy implementation

Abstract The COVID-19 pandemic highlighted the strategic role of social care policy to minimize the effects of this health crisis and its consequences on the poorest and most vulnerable population. This article analyzes the perception of street-level bureaucrats in the Brazilian social care network on how the pandemic has affected their performance and professional routine. The research was based on a survey, consultations with representatives of municipal social care services, and analysis of government regulations. The results show that social workers feel unprotected and unable to provide adequate responses to the pandemic’s increasing and urgent demands, revealing a lack of institutional support to act appropriately. The professionals also reported substantial changes in their working dynamics, particularly in their relationship with the attended population, one of the main pillars of the Brazilian social care network. These elements directly affect the provision of social care services and their potential to combat the adverse effects of the crisis.