key: cord-0722167-xg5c7qy7 authors: Fehn, Amanda Cavada; Alves, Thays dos Santos Guaraciaba; Poz, Mario Roberto Dal title: Higher education privatization in Nursing in Brazil: profile, challenges and trends date: 2021-06-28 journal: Revista latino-americana de enfermagem DOI: 10.1590/1518-8345.4725.3417 sha: 1f915cbc507fafefe1f367681d0727c8db9097c1 doc_id: 722167 cord_uid: xg5c7qy7 OBJECTIVE: this study aims to analyze and characterize the movement of expansion of Nursing undergraduate courses in Brazil since the 1990s. The characteristics of this expansion are discussed, as well as the socio-political setting where such movement occurred, and the quality of education available based on the data collected. METHOD: this is a descriptive and cross-sectional study with a quali-quantitative approach, with the use of secondary databases. RESULTS: an accelerated and disordered growth of Nursing undergraduate courses was identified, as well as the number of vacancies, especially due to the participation of the private sector, especially since the year 2000. Geographical inequalities in the distribution of these courses and vacancies were also identified. CONCLUSION: the strong expansion of higher education in Nursing, along with other health professions, resulted in the strengthening of private higher education institutions associated with economic groups, regional concentration, as well as the excessive offer of distance learning without adequate evaluation of its quality or repercussions. The global growth of Private Higher Education Institutions (PHEIs), especially those for profit in recent decades, has broadened the debate on the nature of public and private assets in higher education and especially on the role of the private sector and its impact on academic education. The educational system responds both to the demands of the health system and to the dynamics of the health labor market. In this sense, educational institutions are recognized as vital in the transformation of the health system and in economic and social development (1) . The phenomenon of privatization in higher education in health has been characterized as a marked dynamic and accelerated growth in education in the 21 st century (2) . Its trends of expansion are especially related to the public policies, which influence, and even encourage, the increase of these institutions (3) . In this study, the term "privatization" includes the expansion of private higher education institutions which offer Nursing degree courses, directed by individuals or companies, and no longer by the State. In this process, there is a tendency to perceive the student as a consumer and education as a product (4) . Privatization also presents as a characteristic a strong appeal of private HEI brands, competition, the exploitation of niche markets with socially prestigious professions, aggressive marketing, and profitoriented pricing policies (5) . In Brazil, the first Nursing school appeared in 1890, in Rio de Janeiro and, in 1939, the first private Nursing institution was created in São Paulo. Until the end of the 1950s there were only 33 Nursing courses in the country, of which 36% were of a private nature, in its immense majority confessional institutions (6) (7) . In July 2019, the number of schools and actual vacancies were 1,348 and 197,995, respectively. While the increase in the number of schools and vacancies can be considered positive, since it has increased access to higher education and improved the proportion of professionals per inhabitant, on the other hand, it has produced inequalities in the distribution of institutions and questions on the quality of education. Additionally, Nursing training in Brazil started to strongly contemplate the Education at Distance (EaD) modality, with 82.000 vacancies offered by 9 Higher Education Institutions (HEIs), all private (6) . There is no evidence on how the increased number of vacancies and schools could solve the problem related to the lack of health professionals (9) . Recent WHO analyses indicate the need for growth in the mean number of Nursing graduates around 8% per year, but stress the importance that this expansion must be linked to greater employability, strategies for the retention of these professionals, development of competencies and skills associated with the needs of health systems, and strengthening governance and leadership in Nursing (8) . reducing the inefficiency of regulatory structures (9) . The understanding of workforce training is intrinsically linked to economic development and has important social, economic and political consequences. It is difficult to assume that large economies reach advanced stages of development without high levels of innovation and quality in education, for example, which can be considered basic components for placing a country at the forefront of the "information society" (10) . In this sense, it is crucial to understand how universities operate in the process of training human resources in market terms, since this reality does not always appear in the public description of their function and often receives a negative connotation (11) . Moreover, it is urgent to understand the factors affecting the size of the future health workforce to plan and propose more effective actions adjusted to each reality (12) . Thus, this article intends to describe, analyze and characterize the expansion movement of Nursing undergraduate courses in Brazil, emphasizing the participation of the private sector, its role, impact and trends in Nursing training in the country. In Brazil, in accordance with the Law No. 7,498/86 (13) , nurses, nursing assistants and technicians, obstetricians and midwives are defined as Nursing professionals. Changes in the education systems have expanded permeability to the private sector (14) . By permeability we can understand the effects of the meeting or overlapping of the State and the private sector in the various stages of production and delivery of public policies (15) . The effects can assume different outlines depending on the relational pattern established at a given time, under certain historical, social, political and economic conditions (15) . The purchase and sale of services is no stranger to the state activity; however, the speed and the characteristics of privatization in the last decades had much proper aspects, especially in the educational sector. In this sense, there are no services exempted from the participation of the private sector; there are those where the private sector operates with less or very little expression (16) . This section initially presents the profile of the privatization process in Brazil, highlighting some elements of the historical context and its characteristics. The following describes the growth trend of the private sector over the past few years and its geographical distribution across states and regions of the country. As far as Brazilian higher education is concerned and from a legal point of view, the State can and has transferred resources to private HEIs. In the case of the public policies that influence and even contribute to the expansion of private higher education institutions, there is a tendency to increase the expressiveness of the private sector in the health sector globally (3) . 3) intense diversification of courses, institutions and teaching modalities, especially distance learning (EaD); and 4) expressive increase of private for-profit HEIs (17) . Rev. Latino-Am. Enfermagem 2021;29:e3417. From 1960 to 1970, a lucrative sub-sector of higher education businesses was created, when the establishments were still considered formally as nonprofit institutions (18) . Another interesting aspect is that, although political scenarios have alternated between different political groups and parties with supposedly different ideals of conformation, orientation and militancy, their leaders have maintained a favorable direction for the expansion of private HEIs (19) . The 1996 Guidelines and Bases Law (Lei de Diretrizes e Bases, LDB) is considered by most authors to be the basis of the privatization process of higher education in Brazil. However, the participation of private for-profit HEIs, explicitly or not, already existed since the 1960s (7, (19) (20) . In the 2000s, the private HEI market was stimulated by public policies associated with public financing mechanisms, which favored the expansion of higher education. In the last decade, the growth, consolidation shareholders. The interest for this branch is evidenced by the diversification of the "products", such as the offer of face-to-face and distance courses, the production of didactic materials, the presence of business consulting and the strengthening of educational marketing, among others (22) . Until the end of the 1940s there were 20 Nursing courses in the country, four in private HEIs. Since 1949, the Brazilian State stimulated the creation of new schools, by making the Nursing course compulsory in all the universities or headquarters of medical schools (23) . Nursing education and the labor market of the time and, therefore, was centered on the clinical model intrinsic to the enlargement of hospitals (24) . Only in the 1950s, iii) public policies that corroborated the expansion of the labor market in the health sector; and iv) educational policies that make HEIs more tolerant and autonomous (25) . However, although the number of vacancies for Nursing undergraduate students has increased considerably, the number of graduates has not followed the same evolution; on average, the evasion percentage of Nursing vacancies is historically higher in private courses than in public courses and corresponds to 38% in public institutions and to 62% in private ones (26) . The Table 1 shows the current geographic distribution of courses and vacancies in Brazil. Regarding the enrollments, in 2018, the private institutions received 91.5%, most of them distributed throughout the Southeast region (37.8%), and followed by the Northeast region (31.1%). The Midwest and North regions had an index of just over 10% (10.9% and 10.5%, respectively) and the South had a lower enrollment rate (9.7%). The Southeast region stands out for having the highest enrollment rates in recent years, as seen in Table 1 . are private (31) . The participation of the private sector in Nursing qualification around the world is very expressive and raises questions, which in general orbit around four topics: i) the contribution of the private sector in the training of Nursing professionals; ii) concentration/distribution; iii) the trend to also be linked to the private sector; and iv) teaching quality (9) . In hospitals are for-profit (57.8%) (33) . The concern with the imbalance in the geographical distribution also occurs in China, where 97 private HEIs are located in Western and Central China, economically more advantageous regions, while only 26 are in Eastern China (27) . The disparities indicate how the interaction between the education system and the health system has been mediated by the Nursing labor market, taking into account the challenges of governance and regulation. The results revealed imbalances and critical mismatches in the demand and supply of nurses, especially in locations outside the major urban centers. In India, for example, only 9% of the Nursing schools are in locations with shortages of such professionals (29) . Although the supply of nurses has grown, it coexists with low rates of absorption of these professionals by the public sector, often due to recruitment inefficiencies or to poor working conditions. A similar setting has been described in Kenya and India, where the imbalance between production (supply) and labor market absorption (demand) has strongly favored the migration of nurses in these countries (20% and Although Brazil is not traditionally a "Nursing labor exporter" country, the growing trend in the number of schools and the high supply of vacancies, coupled with the inability to employ these professionals, suggest a powerful space for migration. In the richest countries, the existence not only of a workforce mostly older and close to retirement, but also of international recruitment companies that, besides subsidizing the language course, offer good employment conditions and social benefits, has increased the interest in Nursing professionals from poor and low-and mid-income countries (PLMICs). At the same time, contexts of economic recession, widely seen in these countries, affect all sectors of the economy, including health professionals. Being the largest professional group in the health sector, nurses are strongly affected by the attempts to balance the budget, whose simplest and quickest alternative for adjustment is the reduction in the supply of workers (34) . Another aspect is the reduction or freezing of the Nursing wages, increasing the number of worked hours and/or of multiple jobs in searching to guarantee personal/family income (34) . In private HEIs, but also with public institutions (11) . Also Internationally, some studies suggest that public institutions, in general, are in a better position to respond to the countries' FTS (34) requirements, in terms of aligning student admissions and training programs with changes in the sociodemographic profile and population needs, maintaining health standards, establishing training schools in rural areas, and collaborating with the public health system, as internship settings during graduation (9, 33) . However, more current studies are urgently needed. The absence of an effective regulation mechanism by the State in Brazilian private higher education can be considered an incentive for expanding this sector (11, 35) . the problem of the growing demand for a sufficient and qualified health workforce. This situation is similar to that of many developing countries that have failed to establish an organic relationship between multi-professional education and the health system. Innovative strategies to address this issue must be developed to contribute to achieving universal health coverage and access. In the current context of the new coronavirus pandemic (COVID-19) , distance learning has become a priority in the HEI agenda, even without much information on its development or its impact on the quality of training of the professionals and on the health labor market, except for the tendency to concentrate the educational offer in a few HEIs. This is a necessary and urgent research agenda in the context of teaching health professions. The study sought to demonstrate the relevance and scope of the privatization process for Nursing education, reflecting on the implications of this process in meeting the demands of the health system in Brazil. Furthermore, it is expected to contribute to the development of a more practical and participatory research agenda involving different actors from the government, academic settings, civil society, private sector and associations, among others, as well as to the process of evidence-based decision-making and political choices. Rev. Latino-Am. Enfermagem 2021;29:e3417. World Health Organization. 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