The Brazilian Health Care Program is formed by a complex network of public and private services that often complement each other, especially in the area of qualified Human Resources for Health (HRH) [1].
The workforce shortage in the health area in remote regions is a reality in Brazil given the social inequalities, especially in the states that make up the Amazon region. In the northern region of the country, located in the Amazon complex, the difficulties are numerous in the performance of health services due to the diversity existing in the states.
Compared to the other regions, inequalities in the cities of the northern region are represented by low Human Development Index-HDI, insufficient health service network and establishment of trained health professionals [2].
The qualification and distribution of health care professionals to meet the population’s demand are considered critical points for the guarantee of a health system with excellence standards [2] and in view of that, the Brazilian federal government has made efforts to bring health professionals to regions considered distant from the major centers and capitals.
However, the difficulty of allocating these professionals in remote areas persists in most cities far from urban centers, as the distribution of health professionals is often not performed in a socially appropriate manner.
Health services that require greater complexity are treated only in the capital cities of the states, a fact that punishes the population upon the vulnerability of people with low purchasing power living in remote areas.
As for the Brazilian federal government, several deficit factors do not serve the population in these areas, starting with the financial transfers compared to the national average and the sanitary infrastructure, which is not adequate to the needs and demands of the people of the region. The government has created several programs to minimize the problem, mainly due to the shortage of medical professionals [3]. The political interventions addressing the issue of the shortage of health professionals in relation to geographic availability and accessibility are: Projeto Rondon, Telessaúde, Pró-residencia, Fies, Provab and Programa mais médicos [1].
In Brazil, the health care program is organized by the public segment of the Federal Program of the Single Health System—SUS, which provides free assistance to all Brazilian citizens in the 5,564 municipalities of the country, and through the private segment, which is restricted to those who are financially able to enjoy this type of service [4].
In the last 50 years, there has been a growth in the medical population in the country; however, this increase in the number of health professionals cannot meet the demands of the most remote regions [5]. “In 2013, Brazil had about 400,000 doctors, corresponding to a rate of approximately two doctors per thousand inhabitants” [5].
In 2019, according to data provided by the Federal Council of Medicine [6], the country has 514,196 doctors in good standing working in all states. The largest medical population is centered in the Southeast region of the country with 276,686 professionals, representing 54% of these professionals.
The northern region, which is part of the Amazon complex, has the lowest number of doctors with 22,884 professionals, representing only 5% of the total doctors in the country.
The distribution of medical professionals in the northern region is organized among the states as follows: Acre with 1,010, Amazonas with 5,164, Amapá with 954, Rondônia with 2,940, Roraima with 913, Tocantins with 2,940 and Pará with 8,963 medical professionals.
In the state of Pará, the supply of 8,963 doctors (approximately 1.6% of the total doctors in the country) to serve around 8,513,497 inhabitants, according to information registered by the government agency Brazilian Institute of Geography and Statistics - IBGE [7]. According to data on the number of inhabitants and professionals, figures indicate that there is one doctor for every 1,000 inhabitants approximately.
In the case of dental surgeons, the Federal Council of Dentistry [8] presents the following numbers for the states: Acre with 866, Amazonas with 4,655, Amapá with 1,041, Rondônia with 2,362, Roraima with 875, Tocantins with 2,256 and Pará with 5,759 dental surgeon professionals. Considering the quantity of inhabitants in Pará, the state has 1 dental professional for approximately 1,500 inhabitants.
Due to the inequalities in the regions, public agencies are prone to create strategic actions for companies and professionals to operate in peculiar markets, “Such strategies imply the reinvention of behaviors that go beyond economic limits, in which social aspects strictly linked to personal and professional values are intertwined in the process regulatory norms” [9].
When considering the health care relationship network, the network is an alternative that can be decisive in the coordinated actions of various services and sectors through the empirical observation of life maintenance. Connected supporters can be considered life support and care networks in the primary care (initial care or simple cases), secondary care (ambulatories and hospital) and tertiary care (more complex care) networks, which are integrated into health services care and actions at their different levels [10].
The network of integrated and regionalized services is formed by the premises of primary health care for the population with multiprofessionals who have the common objectives of sanitary and economic interest [11]. One of the important points of the network is the articulation to reduce risks and share resources to obtain expertise and information.
The Pan American Health Organization [12] points out that “the proliferation of networks shows that this sector has advanced towards freedom, diversity and the sharing of common goals, without losing identity differences”.
Given this reality in the Amazon complex, the few professionals working in these areas face various difficulties and, through the professional relationship network, they seek information and knowledge that add value to their work activities.
The workforce of networked medical professionals can be a practical outlet to meet the demand for health maintenance services through flexibility and connectivity for using shared communication as a growth strategy, thus transforming individual development into collective development.
Research from the perspective of the social network is important for academia since there is no research addressing the solidarity cooperation between health promotion professionals, supported by a network of doctors, dentists, physiotherapists and occupational therapists who share the same demands, difficulties and prospects around benefiting the local population.
Given these findings, the following question arises: How health professionals in the city of Rondon do Pará, a district located in the Amazon region, far from great centers, form a social network, and generate cooperative behavior in the face of diversity and difficulties for performance of the health profession in serving the population.
The purpose of this research is to explore and analyze the cooperative behavior network among these professionals, as well as to know the difficulties faced in the exercise of the function in this region considered a region that lacks infrastructure, located in the heart of the Amazon complex, very difficult to access, due to local adversities.
- Social or Interorganizational Networks in the form of Cooperative Behavior Network
The people or organizations that participate in a network are willing to socialize activities among the players and are intended to share information and knowledge through interactions [13]. According to the authors, acting in the network fosters trust, commitment and integration regarding the exchange of experiences and skills.
“The exchange of ideas, opinions and beliefs provided by conversations enables the first and most important step towards knowledge creation: The sharing of tacit knowledge within the network community” [14].
Relationship networks are understood as interorganizational strategies that go beyond the economic limits of social aspects related to personal and professional values. Network studies can happen through their form or content, studied through the connections between people, informal groups or organizations in their forms of relationship intensity and engagement measures, through content with their relationship measures and documents and reports made, and may be of social, economic or friendship and kinship, as well as of status and politics among others [15].
Existing interorganizational cooperation is increasingly considered as the development strategy process, especially in education and health organizations, which are motivated by essential knowledge to health promotion and quality services [9]. Noting that professionals who work in this perspective deal with the life, death, well-being and suffering of the individual, as well as of the population in general.
“Health promotion and training needs require mobilization and interrelation with various social partners in order to respond to community problems with quality” [9].
Relationship networking through its members’ social networks could better manage available resources such as capital and political influence [16], the intensity of social ties can allow free sharing of information and knowledge through mutual learning and innovation [17].
The study of the network is related to the understanding of the relationship of the players or individuals as well as their attributes, aiming to understand how the players are related to each other and how these relationship activities act in the contribution of a social life[18].
The network presents the structure through the factors: Us (companies and activities), positions and links (division of labor) and flows of goods and information [19].
The relationships stories with other individuals or social groups and their cultures result from their own social identity [20], where the set of interpersonal relationships are constituted by the social network of people inserted in a relational context [18].
Network analysis can be defined as an instrument of social analysis [21] and behaves as an inductive instrument of social investigation of relationships between players for the systematic measurement of the links [22].
The relations between the network members are characterized by ties that are connected to the players of the inserted network, as well as the degree of intensity through mutual commitment and reciprocity through conditions of being bidirectional or not (when flowingon both sides)[23]. Ties can be attributed to existing bonds and can be multiple from this player’s involvement with various other players or through intense or weak relationships depending on the involvement [24]. Connectivity or the ability to interconnect individuals is directly dependent on the frequency of communication between the players [25].
For this research were used the players’ attributions regarding the ties (relations, links, connections) between them, as the measures of:
- Density: Which is the ratio between the number of relationships in the network versus the number of relationships possible. This metric deals with the number of existing interrelations by increasing or decreasing the density of relationships within the social network. This measure results from the exchange of information and resources and a closed system of trust and shared standards in the social network. The network acts as interactions between the players involved through common interests for the purpose of exchanging knowledge and mutual cooperation [26]. “From the degree, it is possible to understand the general functioning of the network, specifically in relation to the performance of each player, by analyzing their relationships with other players” because the greater the number of links, the greater the ability to influence other players in the network [27].
- Reciprocity: Which is the ratio of the amount of reciprocal relationships versus the number of network relationships. Reciprocity is represented by the number of two-way connections divided by the number of connections, that is, which professionals are reciprocal in cooperative health relations. Reciprocal ties must be linked to a relationship of agreement between the players for knowledge exchange [28].
- Betweenness: Intermediate players may have some control over the interactions of non-adjacent players. Intermediation “represents how much a player acts as a bridge, facilitating the flow of information in a given network” and this intermediation is based on the interaction between two non-adjacent authors [29].
- Degree - indegree and outdegree: Which is the ratio of the amount of connections that each player has (i.e. how many professionals cooperate with such player). This measure is based on the number of links or ties that exists between the network players. The degree metric indicates how many links or ties are presented in the network between the players and respectively how many links each player presents according to the demand or supply of relationships [22, 23].
“The greater the number of bonds (ties) of a player, the greater their degree, which indicates a more favored position, a position that exchanges more information and, thus, with greater influence on the network” [27]. The degree metric can be classified as indegree and outdegree and differ in the sense of the relation to demand or to offer information exchange. For example, in the indegree classification, player X has an indication of how many professionals he cooperates with professionally and in the case of outdegree, how many professionals cooperate with him.
- Core-periphery: Indicates which players belong to the center of the network, i.e., cooperate more (core) and which players cooperate less, that is, are in the periphery of the network (periphery).. In order to understand the cohesion of the network, the formation of groups and the strength of ties/relationships of the players, the center-periphery metric is used to identify the center and the periphery of the network, thus contributing to the understanding of the grouping of players [ 30].The cores can be presented as a space of concentration of several links, in which the players are strongly connected to each other and, in contrast to the peripheries, are characterized by few relationships, in which the players are little related, that is, they cooperate less among them which indicates less cohesive subgroup formation [27].