Otolaryngology is a core surgical specialty that plays a crucial role in population health by addressing diseases that impair communication, breathing, and hearing. From chronic ear disease in children to head and neck cancer in adults, these conditions impose a high burden of disability and economic loss.1 Under universal health coverage, access to timely and safe otolaryngologic care is therefore a key determinant of social well-being and equity.2 In Brazil, where 76% of the population depends exclusively on the unified public health system (SUS), the equitable delivery of surgical care represents one of the greatest challenges of the public health agenda.3 Recognizing this, the Ministry of Health recently launched the “Now There Are Specialists” programme to expand the number of specialists in priority fields, including otolaryngology. The programme aims to correct workforce imbalances and strengthen capacity to meet surgical demand, but whether workforce growth alone translates into greater surgical provision remains uncertain.

This national debate aligns with the broader global movement for surgical equity, galvanized by the 2015 Lancet Commission on Global Surgery (LCoGS), which established that access to safe, timely, and affordable surgery is an essential component of universal health coverage.4 Surgical conditions account for nearly one-third of the global burden of disease,5 and workforce distribution has emerged as a key determinant of access, particularly in Low-Income and Middle-Income Countries (LMICs), where rural and underserved populations face persistent barriers to specialized care.6–9 Within this framework, otolaryngology occupies a strategic position: it bridges essential, emergency, and elective procedures, serving both pediatric and adult populations.

Despite the growing global interest in surgical workforce distribution, no previous research has specifically evaluated the geographic distribution of otolaryngologists in Brazil or its implications for surgical care delivery. This knowledge gap is critical, given Brazil’s continental dimensions, marked socioeconomic disparities, and the SUS mandate to ensure universal access, as it represents one of the largest public health systems in the world.3 Understanding how the spatial distribution of otolaryngologists correlates with surgical productivity and access is essential to inform targeted workforce policies. Such evidence can guide strategic investments that not only expand specialist availability, but also translate workforce expansion into measurable improvements in population health. Therefore, the present study aims to analyze the geographic distribution of otolaryngologists across Brazil and assess its association with the provision of surgical care within the public health system.

This study examines otolaryngologic surgical provision in Brazil between 2008 and 2024, focusing on the geographic distribution of specialists, surgical volumes, costs, and system-level factors associated with service delivery within the public health system. During the study period, the national density of otolaryngologists increased by 64.7%, while relative measures of inequality between states declined. Nevertheless, substantial regional disparities persisted, with higher workforce availability and surgical rates concentrated in the South and Southeast. Cluster analysis further indicated a socioeconomic gradient, with poorer regions showing lower workforce density, surgical rates, and expenditure levels than wealthier regions. Multivariable modelling indicated that otolaryngologist density was significantly associated with surgical rates per capita. However, the estimates presented in Table 3 suggest that this association weakened over time, which could represent progressively smaller gains in surgical output corresponding to each additional specialist. These findings align with the premise of the LCoGS that equitable surgical access in low-income and middle-income countries requires concurrent investments in workforce, infrastructure, and system capacity.4,6

The spatial heterogeneity observed in this study is consistent with patterns reported in other LMICs health systems, where specialists tend to be concentrated in economically developed regions.3,7 Although the coefficient of variation and Gini index for otolaryngologist density declined over time, substantial absolute differences between states remained. Persistently low densities in states such as Amapá, Roraima, and Acre could reflect ongoing challenges in attracting and retaining specialists in underserved regions. These disparities may originate early in the training pathway. According to the 2025 National Medical Demography Report, approximately 234 otolaryngology residency positions are offered annually in Brazil, with nearly 68% located in the Southeast and only about 3% in the North. This concentration of training opportunities could contribute to persistent workforce imbalances and may limit the renewal of specialists in regions with greater unmet surgical need.

The decline in surgical productivity per otolaryngologist observed during the study period could reflect multiple overlapping factors. The sharp reduction observed in 2020 coincided with the onset of the COVID-19 pandemic, a period characterized by widespread cancellation of elective procedures, reallocation of hospital resources, and restricted access to operating rooms. As a specialty that relies heavily on elective inpatient procedures, otolaryngology was particularly vulnerable to these disruptions.12 However, a gradual decline in the ratio of surgeries per specialist was already evident between 2011 and 2018. As shown in Table 1, this pattern occurred despite stable or increasing absolute surgical volumes and could partly reflect the rapid expansion of the otolaryngology workforce. Because surgical productivity was defined as the number of procedures performed per practicing specialist, a rapid increase in specialist density could mechanically reduce the number of surgeries attributed to each physician. These findings suggest that workforce expansion alone may not be sufficient to substantially increase surgical delivery without parallel investments in structural capacity. Limitations in operating room availability, anesthesia staffing, inpatient beds, and perioperative support could restrict the system’s capacity to absorb additional specialists. Similar patterns have been described across surgical specialties, suggesting that infrastructure and organizational capacity could represent important constraints on surgical productivity within public health systems.13

Approximately 70% of the surgical volume consisted of adenotonsillectomy, which reflects the routine surgical profile of otolaryngology within Brazil’s public health system, where this procedure is the most frequently performed operation. Nevertheless, the analysis was not limited to adenotonsillectomy alone and also encompassed other inpatient procedures with greater infrastructure requirements, including septoplasty, sinus surgery, tympanoplasty, and mastoidectomy, across which similar regional gradients were observed. Because the SIH/SUS database captures only inpatient procedures reimbursed within the public health system, the overall provision of otorhinolaryngologic care may be underestimated, particularly regarding outpatient procedures and services delivered in the private sector.

The “Now There Are Specialists” programme, launched by the Ministry of Health to expand priority specialties, represents a national initiative aimed at addressing workforce imbalances in specialist care. Otolaryngology was included among the programme’s priority areas, reflecting the specialty’s role in conditions affecting communication, airway function, and hearing. However, the findings of this study suggest that increases in the number of specialists alone may not necessarily translate into greater access to surgical care within the SUS. Although the otolaryngology workforce expanded during the study period, the number of surgeries performed per specialist declined, a pattern that could reflect limitations in structural capacity, including hospital infrastructure, operating room availability, anesthesia services, and perioperative support. These findings may provide useful considerations for the implementation of the programme, suggesting that workforce expansion could be more effective when accompanied by investments in hospital infrastructure and perioperative capacity at the regional level.1,4

From a policy perspective, these results suggest that workforce expansion and infrastructure development may need to progress in parallel to support improvements in surgical provision. Expanding the number of specialists without corresponding structural capacity could potentially result in underutilized workforce capacity and persistent geographic disparities in access to care. The diminishing marginal associations observed in this study could also reflect constraints in existing surgical capacity in some regions, where additional specialists may not translate into higher surgical output in the absence of investments in hospital beds, equipment, and support staff.4–7 Similar patterns have been described in other middle-income countries, where workforce growth occurred alongside more limited expansion of surgical infrastructure.14

In a global context, Brazil’s otolaryngology workforce density remains relatively modest. In 2024, the country reached 3.97 otolaryngologists per 100.000 inhabitants, less than half the levels observed in high-income countries such as Germany or France, where densities exceed 7.0 per 100.000 and distribution is more balanced.13,15,16 In contrast, Brazil’s regional patterns appear more comparable to those observed in other middle-income Latin American countries. In countries such as Colombia and Chile, surgical and otolaryngologic services are concentrated in large metropolitan centers, while rural and peripheral regions often face persistent shortages of specialists and longer waiting times for elective procedures.17–19 Similar to Brazil’s SUS, these systems operate under decentralized health frameworks with marked regional inequalities in access to specialized surgical services. To our knowledge, this study is among the first national-level analyses to examine the diminishing marginal association between specialist expansion and surgical provision within a public health system.

In comparison with international data, the proportion of otolaryngologic surgeries observed in Brazil appears lower than that reported in high-income countries. National surgical rates in our study ranged approximately from 8 to 34 otolaryngologic procedures per 100,000 inhabitants, depending on the state cluster, with a national average close to 20 procedures per 100,000 inhabitants, despite the observed increase in specialist density over time. In contrast, population-based data from the United States report otolaryngologic surgical rates commonly exceeding 40–50 procedures per 100,000 inhabitants per year.1,19 Similarly, data from Western Europe describe otolaryngologic surgical rates ranging from 30 to 50 procedures per 100,000 inhabitants. These comparisons suggest that higher surgical rates may be more likely when workforce expansion occurs alongside broader growth in health system capacity.20

In middle-income and lower-resource settings, reported otolaryngologic surgical rates are generally lower, often below 10–20 procedures per 100,000 inhabitants, even in countries with expanding specialist workforces. International assessments suggest that, in these contexts, increases in specialist numbers do not always translate into proportional growth in surgical provision.21 The Brazilian experience appears consistent with this pattern. Although the otolaryngology workforce expanded substantially during the study period, the number of surgeries performed per specialist declined over time. A further reduction was observed in 2020, coinciding with the onset of the COVID-19 pandemic. From an international perspective, Brazil may therefore occupy an intermediate position between high-income systems with higher surgical throughput and lower-resource settings where surgical provision remains more limited. These observations suggest that expanding specialist numbers alone may not necessarily lead to proportional increases in surgical delivery within the public health system.12

The cost analysis presented in Table 3 showed persistent regional differences in public expenditure per otolaryngologic procedure, with the South and Southeast reporting the highest average values. For complex procedures such as advanced otologic surgeries, average expenditures in the Southeast were more than twice those observed in the North. These differences could be associated with structural factors, as wealthier regions may have greater availability of specialized surgical centres, broader access to high-cost consumables and technology, and a higher proportion of complex procedures.22–24 In contrast, poorer regions may present a case mix more concentrated in lower-cost routine procedures, which could be related to differences in available equipment and subspecialty expertise.25–27

For policymakers implementing the “Now There Are Specialists” initiative, these findings may offer considerations regarding the broader conditions required to support improvements in surgical provision. Expansion of training programmes and hiring quotas could be more effective when accompanied by efforts to strengthen the physical and operational capacity of the SUS and referral coordination across levels of care. Sustainable implementation may also depend on stable financing mechanisms for surgical services at the federal and state levels, as well as policies that encourage the retention of specialists in underserved regions through structured career pathways, targeted funding, and regional infrastructure development. Without such coordination, increases in the number of specialists alone may not necessarily translate into substantial improvements in access, particularly for populations who rely primarily on the public health system.

Finally, these findings reinforce the need for Brazil’s ongoing health reforms to adopt a system-level approach to surgical care. Aligning workforce planning with infrastructure investment, financing, and equitable regional distribution can transform the “Now There Are Specialists” programme into a long-term instrument for reducing surgical inequities. Ultimately, the programme has the potential to reshape surgical equity in Brazil if implemented as part of an integrated system-strengthening agenda, one that treats workforce expansion not as an end, but as a catalyst for broader investment in hospitals, infrastructure, and perioperative care. The evidence presented here provides policymakers with concrete data to guide this alignment and to ensure that the expansion of otolaryngology training and practice translates into tangible improvements in surgical access, outcomes, and equity across Brazil.

The expansion of the otolaryngology workforce in Brazil was accompanied by comparatively smaller increases in surgical provision across regions. Despite substantial growth in specialist numbers, surgical delivery appears to remain limited. These findings suggest that improvements in surgical access may also depend on broader health system capacity.

Arthur Menino Castilho: 0000-0002-9024-8004

LSS and AMC contributed equally to the conceptualization and design of the study, data collection, formal analysis, data interpretation, original manuscript drafting, critical revision of important intellectual content, and approval of the final manuscript version. SFO contributed to data analysis, result interpretation, original manuscript drafting, manuscript revision, and critical revision of important intellectual content. RGFA contributed to data collection, manuscript revision, assistance in data interpretation, and critical revision of important intellectual content. VARS contributed to data analysis, manuscript revision, and critical revision of important intellectual content. All authors approved the final version of the manuscript and agree to be accountable for all aspects of the work.

No financial or material support was received for this study.

The data that has been used is confidential.

Data will be made available on request.