In the first part of their analysis of nurses’ working conditions in Brazil, Outra Saúde explored the systemic exploitation and deteriorating working conditions faced by health workers in Brazil, highlighting how these challenges are shaped by internal labor dynamics and policy changes. In this second part, the focus shifts to examine the external pressures exacerbating the crisis.
In the realm of labor relations in Brazil, one of the key drivers of the precarious conditions affecting nursing workers—and other health workers—has been the rise of Social Organizations (Organização Social, OSs). These private entities, introduced through legislation enacted during the Fernando Henrique Cardoso (FHC) administration, have increasingly taken on roles in managing public services within the Unified Health System (SUS).
“OSs represent a significant weakening of all the professional categories subjected to this model, and this was no accident,” explains Professor Paulo Henrique de Almeida. “In my view, this approach was deliberately introduced into the health sector during the neoliberal era of the FHC government, leaving behind a brutal legacy of worker subordination and national dependency, with the political goal of intensifying super-exploitation.”

Data from the 2023 National Register of Health Establishments (CNES), analyzed by the researchers, reveals a troubling trend: the proportion of nurses in the public sector with statutory employment—which offers job stability—has fallen to 22.75%. A few decades ago, these workers constituted the majority. Meanwhile, the numbers of temporary and contract employees, common forms of employment in the OSs, have climbed to 23.94% and 23.83%, respectively. These shifts have brought significant consequences, which have been a focus of the studies of the Health, Society, State, Market research group (Grupo SEM).
“Most workers today are hired under very precarious contracts. In the public sector, civil service exams are becoming increasingly rare, replaced by simplified selection processes. This undermines job security and weakens the ability of workers to organize, as they can lose their jobs at any moment,” explains Professor Inês Leoneza.
While OSs often lower salaries and increase working hours for employees, researchers point out that these changes have not resulted in savings for the health budget. “OSs create massive inefficiencies, particularly due to constant turnover. A striking example is the Family Health program in Rio de Janeiro. When one OS is replaced by another—which happens frequently—a significant portion of the team is dismissed, and new staff must be hired and trained, incurring additional costs. They conceal this inefficiency to make OSs appear like miracle solutions, claiming cheaper payroll costs. But that’s false. Not only does it generate inefficiency, it worsens the quality of care and working conditions,” says Professor de Almeida.
For those unable or unwilling to endure the harsh working conditions, whether due to exhaustion or resistance to the system’s logic, OSs have often resorted to summary dismissals. “The OSs rely heavily on performance targets, which our research shows translates into an increased intensity of work. Workers face pressure to meet ever more unrealistic goals, and without job stability, they risk being fired at any moment if they challenge this approach,” adds Grupo SEM member Thauanne Gonçalves.
Unsurprisingly, recent data highlights a staggering unemployment crisis among nurses in Brazil, with one in every four nurses being unemployed. With 24.5% of professionals jobless, nursing ranks as the fifth-highest degree field for unemployment in the country, trailing behind history (31.6%), international relations (29.4%), social work (28.6%), and radiology (27.8%).
The imperialist offensive
In this challenging context for the nursing profession, a troubling new trend has emerged: major economic powers, particularly Germany, are actively recruiting large numbers of workers from Brazil and other dependent countries. They promise high salaries and a better quality of life in the so-called First World, but reality often falls short of these promises.
“These countries face a shortage of workers in these positions. But instead of investing in training their own workforce, they target other countries for highly skilled professionals, often educated through public funds,” explains Gonçalves. “Here in Rio de Janeiro, we know of many cases of federally trained nurses who have migrated to Germany. Think about how much the state has invested in their education, only to see them leave.”
As highlighted by organizations like the International Council of Nursing and trade unions, and covered by Outra Saúde, these nurses often face significant challenges upon migrating. It can take years for them to gain professional registration, forcing many to take informal, low-paying jobs as caregivers or assistants under terrible conditions. Reports of xenophobia, inadequate support for linguistic and professional adaptation, and the high cost of living in Europe are common among those who have made the move.
Even when they succeed in registering as nurses, migrant workers often earn less than local professionals, although their salaries may still surpass what they would earn in Brazil. In practice, this confirms that their recruitment is designed to address labor shortages in wealthier countries at a minimal cost to those imperialist nations.
For the researchers, it is understandable why many nurses accept such opportunities given the dire state of Brazil’s labor market. However, what is concerning is the lack of action from professional councils and even the Ministry of Labor to counteract or regulate this foreign interference—or worse, their apparent collaboration in the process.
“On an individual level, we can’t fault the people who migrate. But we must hold the state accountable,” Gonçalves states. “In addition to losing the resources spent on their education, these professionals are vital to the SUS. For it to function fully and provide adequate care to the entire population, we need policies that support employability here at home.”
“The age of nursing”
The global race to attract nurses from dependent countries highlights an important paradox: the overexploitation of nurses in Brazil doesn’t diminish the value of their work—on the contrary, it underscores a massive and growing demand for the care they provide. At the same time, healthcare is increasingly being recognized by governments as a strategic sector.
“Healthcare is one of the largest economic sectors in the world. It’s huge everywhere, and in Brazil, it represents around 10% of GDP. Because it’s such a large and strategically important sector, it naturally draws strong class interests from the bourgeoisie against the workers in this field. The reforms of recent years have been designed to subjugate these workers to boost profit margins,” says de Almeida.
In his view, reversing this trend requires major action. “A broad movement against the labor reform and for the repeal of the Fiscal Responsibility Law is essential,” he says, referring to these as key tools that have led to precarious working conditions—weakening labor rights and imposing budget restrictions on public sector hiring. “The popular struggle was fundamental in securing the right to health in Brazil. It was social mobilization that made health reform possible,” he adds.
The growing recognition of care work’s importance could serve as a rallying point for the fight to secure the dignity that nurses deserve. Despite achieving a minimum wage, researchers note that nursing salaries remain below the minimum calculated by the Inter-Union Department of Statistics and Socio-Economic Studies (DIEESE). “We’re living in a time when people have never lived so long, and this increased lifespan places greater demands on the healthcare system,” explains the State University of Rio de Janeiro (UERJ) professor. “The support required at advanced ages isn’t individual—it’s team-based. And within that team, nurses play a central role. They accompany patients throughout the day, monitor their progress, and essentially act as care managers.”
“We’re entering what could be called the ‘age of nursing.’ There’s never been a better moment to recognize and value the nursing profession,” de Almeida concludes. “There’s enormous potential to raise awareness, and our work producing knowledge is committed to driving this change. Without contributing to the organization of workers, our work would be incomplete.”
The article was originally written by Guilherme Arruda and published in Portuguese on Outra Saúde.
People’s Health Dispatch is a fortnightly bulletin published by the People’s Health Movement and Peoples Dispatch. For more articles and to subscribe to People’s Health Dispatch, click here.