Nursing in Brazil: a story of super-exploitation

Research reveals alarming data on the worsening conditions faced by nurses in Brazil: falling wages and increased precarization push many to work up to 80 hours a week

December 17, 2024 by Outra Saude
Foreign recruitment of nurses Germany, Brazil
(Photo: via Twitter)

Nurses in Brazil have taken to the streets over the past two years to demand a living wage. Despite only partial victories due to judicial setbacks, their mobilization—representing a group of 3 million workers—has drawn significant attention to the poor working conditions they face. These challenges also extend to other segments of the health sector.

But the notorious difficulties nurses face in Brazil go far beyond low wages: they also deal with long hours, juggling multiple jobs just to make ends meet, and increasingly precarious employment arrangements. For a research group in Rio de Janeiro, one word—or rather, one concept—sums up the reality of their experience: super-exploitation.

“In this system, Brazil is forced to transfer value to imperialist countries. In a country where health accounts for 10% of GDP, this happens through the overexploitation of health workers, an area increasingly dominated by multinational capital,” explains Paulo Henrique de Almeida, a professor at the Institute of Social Medicine at the State University of Rio de Janeiro (IMS/UERJ). This conceptual approach highlights an important point: the exploitation of nurses is tied to Brazil’s dependent position in the global system. It’s no coincidence that Brazil faces aggressive recruitment efforts by countries using predatory practices to attract its health workforce, especially nurses.

Members of the Health, Society, State, Market research group (Grupo SEM), including UERJ doctoral student Thauanne Gonçalves and UFRJ professor Inês Leoneza, are conducting studies that take a deeper look at the working conditions of nurses today. In an interview with Outra Saúde, they provided concrete data on the precarious situations nurses have endured in recent years, particularly after the 2017 labor “reform,” and discussed potential ways to fight for dignified working conditions in the face of the growing neoliberal wave.

Wages fall, working hours grow

The Marxist dependency theory, which underlies the Grupo SEM’s research, serves as a “method for understanding capitalist dynamics” and is particularly useful for understanding what is happening in Latin America. The existence of “rich” and “poor” countries is inextricably linked, according to Brazilian theorists such as Ruy Mauro Marini, Vânia Bambirra, and Theotônio dos Santos, who developed this framework: in the current global order, the wealth of dependent countries is systematically extracted by the imperialist powers.

This transfer of value doesn’t just occur through the massive profits foreign companies operating in Brazil send abroad or through economic dependence on imported goods and technologies. It also involves the overexploitation of the workforce. From this point of view, the inhumane working conditions faced by Brazil’s labor force—including those in both public and private healthcare—reflect not only employer greed but also the subordinate position of the country’s economy within the global hierarchy.

Because nurses represent 52% of the workforce in Brazil’s Unified Health System (SUS) and 56% of the health workforce in the Americas, according to the Pan American Health Organization (PAHO), “nursing becomes the most visible face of overexploitation” in the sector, explains Professor Inês Leoneza, who has worked as a nurse for 37 years. “It’s a huge group of workers. This year, registrations with the Federal Nursing Council (Cofen) surpassed 3 million, including around 800,000 nurses, 1.8 million technicians, and 400,000 nursing assistants,” adds researcher and nurse Thauanne Gonçalves, who has published a scientific article on overexploitation in nursing.

The pair’s research has revealed a critical indicator of this exploitation: in 2021, for the first time, the real average wages of nurses fell below the minimum living wage calculated by the Inter-Union Department of Statistics and Socio-Economic Studies (DIEESE). The wages of technicians and assistants, already lower, remained stagnant. One major factor driving this trend, the researchers argue, is Brazil’s 2017 Labor Reform.

Remuneration for nursing workers is falling. Graph from Grupo SEM, with data from RAIS.

In the graph produced by the Grupo SEM, the average pay of nurses shows a slight decline, but a closer look reveals a more alarming reality. To maintain their income levels, many nurses have taken on multiple jobs—often working three or four shifts in a row. In other words, while salaries offered by health employers in Brazil are actually decreasing, the accumulation of jobs by workers masks this drop in the average income figures.

The most recent data, from the 2017 edition of the Nursing Profile Survey survey, shows that at least 40% of nurses and 36% of technicians and assistants work more than 40 hours per week. Although more recent figures have yet to be consolidated, there are indications that this percentage has grown since then, spurred by the labor reform and the weakening of employment protections. Today, hundreds of thousands of nurses work over 60 hours a week—an exhausting workload that, in some cases, exceeds 80 hours.

Increasingly strenuous working hours for nurses. Graphs from Grupo SEM with data from the Nursing Profile Survey.

“Working hours are exploitative for everyone. Most nurses work 12×36 shifts [a model where, in theory, nurses work 12 continuous hours followed by 36 hours of rest]. However, since most don’t have a single employment contract, they end up working 12 hours every day without any rest, often under worsening conditions with a lack of materials and equipment. It’s not just exploitation—it’s precariousness, and more importantly, it’s a lack of dignity,” says Leoneza.

When considering that unions are fighting to establish a 30-hour workweek as a standard, the gap between current conditions and the ideal scenario becomes evident: less than 15% of nurses currently work schedules that meet or fall below this standard.

The research group highlights several reasons behind the challenges faced by nurses regarding pay and labor rights. “Because of the level of education, nursing is already a profession that tends to be lower paid and comes with inferior working conditions,” explains Gonçalves. “In other health professions, as we’ve seen through other areas of our research, conditions are bad too. But they’re worse in nursing because most workers are technicians, not university graduates.”

Race and gender also come into play. “We can’t overlook that 85% of the nursing workforce is made up of women, nearly half of whom are Black. These women already face historically and socially high weekly workloads. Their working hours are already absurd, and then they come home to carry the additional burden of domestic responsibilities,” Gonçalves explains.

“The challenges nurses face in pushing their agendas stem from the socio-historical foundation of the profession itself. Nursing is a predominantly female profession, which influences the bargaining power of this group. On top of that, it involves care work—historically unpaid labor—which means it’s not socially recognized as a job deserving of decent pay. Let me be clear: it’s not that nurses don’t fight—they fight incredibly hard. But for various reasons, they face more obstacles in achieving their goals,” the UERJ researcher concludes.

The fierce competition over health budgets is another factor contributing to low wages in the profession. Dependency, as the researchers point out, plays a central role. Billions of reais that could be invested in valuing public health workers are instead spent on supplies, medicines, vaccines, and equipment purchased from multinational companies because Brazil doesn’t produce them domestically. The situation in the private sector is no better: an increasing share of revenue generated by supplementary health groups is being funneled into the pockets of foreign financial shareholders. These investments shrink the margins allocated to employee wages, leaving workers even more exploited.

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.