ABSTRACT

The objective of this article is to analyze Brazilian health specialists’ perceptions of the possibilities of country achieving the Sustainable Development Goals (SDGs) by 2030, especially in regard to the targets of SDG 3 – Good Health and Well-Being. Specialists are defined as the main author of an article in the field of public health, published between September 2012 and 2017 in periodicals indexed in the Web of Science (WoS) platform. Their perceptions were collected using a distance research technique, with the use of an electronic research instrument, received and returned by e-mail, by 884 respondents (research universe), Between 22 January and 2 February 2018 (field of research). Respondents, with a ‘medium’ and ‘high’ knowledge of SDGs, considered Brazil’s possibilities of achieving any of the 17 objectives as ‘low.’ For them, the country should prioritize SDG 4 (Quality Education) and 1 (End Poverty), also seen as those that would contribute most to achieving SDG 3 (Health and Welfare). In terms of policy recommendations that could help achieve the nine targets of SDG 3, respondents stressed ‘poverty reduction’, ‘universal primary care’ and ‘education’ as priorities.

KEYWORDS
Sustainable development goals; Health policy; Evidence-informed policy

Introduction

Agenda 2030 is a United Nations (UN) initiative proposing a global pact for sustainable development. Its principal purpose is to guarantee human development and the fulfillment of the basic needs of individuals through an economic, political, and social process which respects the environment and sustainability¹1 Organização das Nações Unidas. Transformando o nosso mundo: a agenda 2030 para o desenvolvimento sustentável. Resolução A/RES/70/1 [internet]. Nova Iorque: UN; 2015. [acesso em 2019 mar 15]. Disponível em: https://nacoesunidas.org/wp-content/uploads/2015/10/agenda2030-pt-br.pdf.
https://nacoesunidas.org/wp-content/uplo... .

Ratified in 2015 by 193 countries, this Agenda consists of 17 Goals – called ‘SDGs, Sustainable Development Goals’ – consisting of 169 targets which have to be met by 2030. Broad-ranging, diversified, and demanding the interaction of goals, this proposal involves a diversity of fields of action which include the eradication of poverty and hunger; health and welfare; education; gender equality; access to drinking water and sanitation; clean energy; decent work; sustainable economic growth; reduction of social inequalities; sustainability of life; infrastructure innovations; responsible consumption; healthy cities; climatic responsibility; reduction of inequalities; efficient institutions; and social peace.

SDG 3 is concerned with Health and Well-Being and has nine ambitious targets which cover the reduction of maternal, infant, and premature baby mortality due to non-transmissible diseases, road accidents, dangerous chemical products and environmental contamination and pollution; the extinction of the epidemics of Aids, tuberculosis, malaria, neglected diseases, and the combat of hepatitis; the promotion of mental health; the prevention and treatment of drug and alcohol abuse; universal access to reproductive and sexual health services; and universal health cover, including the protection of financial risk, access to quality services, and essential and safe vaccines and medicine²2 Plataforma Agenda 2030 - acelerando as transformações para a Agenda 2030 no Brasil [internet]. Brasil. IPEA; PNUD. [acesso em 2019 mar 15]. Disponível em: http://www.agenda2030.org.br/ods/3/.
http://www.agenda2030.org.br/ods/3/... .

Despite the global dimension and ambition, the political strategy for the implementation of SDGs has a national emphasis as the government of each country determines priorities, structures of governance, monitoring of results, and forms of finance. This happens in a scenario in which an important part of SDGs – if not all – demand, at the very least, dialogue with large transnational corporations (as in the very recent case when Brazilian trade unionists went to the headquarters of Ford in the United States to try to prevent the closure of a factory in the ABC Paulista and received no support from the Brazilian government nor was their venture successful³3 Contra fechamento de fábrica em São Bernardo, metalúrgicos vão à sede da Ford nos EUA. Revista Fórum [internet]; 2019 [acesso em 2019 mar 21]. Disponível em: https://www.revistaforum.com.br/contra-fechamento-de-fabrica-em-sao-bernardo-metalurgicos-vao-a-sede-da-ford-nos-eua/.
https://www.revistaforum.com.br/contra-f... ), with the multilateral organizations which organize the economy and the global market,⁴4 Almeida C. Parcerias público-privadas (PPP) no setor saúde: processos globais e dinâmicas nacionais. Cad. Saúde Pública [internet]. 2017 [acesso em 2019 mar 21]; 33(2):e00197316. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2017001403002&lng=pt.
http://www.scielo.br/scielo.php?script=s... and with the geopolitical blocs which nations construct⁵5 Galvão OJA. Globalização e mudanças na configuração espacial: da economia mundial: uma visão panorâmica das últimas décadas. Revista de Economia Contemporânea [internet]. 2007 [acesso em 2019 mar 21]; 11(1):61-97. Disponível em: https://dx.doi.org/10.1590/S1415-98482007000100003.
https://dx.doi.org/10.1590/S1415-9848200... .

By not presenting strong global proposals for governance and financing which effectively supported national governments, Agenda 2030 deals with the risk of SDGs being fulfilled in an unequal manner around the world, with some not even obtaining partial results⁶6 Alves JED. Os 70 anos da ONU e a agenda global para o segundo quinquênio (2015-2030) do século XXI. Rev. bras. estud. popul. [internet]. 2015 [acesso em 2019 fev 27]; 32(3):587-598. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-30982015000300587&lng=pt&nrm=iso.
http://www.scielo.br/scielo.php?script=s...

7 Buss PM, Machado JMH, Gallo, E, et al. Governança em saúde e ambiente para o desenvolvimento sustentável. Ciênc. Saúde Colet. [internet]. 2012 [acesso 2019 fev 27]; 17(6):1479-1491. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232012000600012&lng=pt&nrm=iso.
http://www.scielo.br/scielo.php?script=s... ^-88 Buss PM, Magalhães DP, Setti AFF, et al. Saúde na Agenda de Desenvolvimento pós-2015 das Nações Unidas. Cad. Saúde Pública [internet]. 2014 [acesso em 2019 fev 27]; 30(12):2555-2570. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2014001202555&lng=pt&nrm=iso.
http://www.scielo.br/scielo.php?script=s... . While the countries which most need to make efforts to comply with the SDGs are those classified as ‘developing’ and ‘poor,’ it should be noted that for most of them their national budgets have not been capable of propelling the development which the Agenda proposes, above all when submitted to expenditure restriction policies, a reduction in the role of the state, and restrictions on investments.

For a number of years Brazil has been an example of this. Reversing a trajectory of growth, investments in social protection, and a reduction in inequalities and poverty, in 2016 the country adopted a political and economic agenda aimed at a heavy financial adjustment, the reduction of the inductive role of the state in development, and deregulation of labor relations. Various political actions have been implemented in this sense, with the most representative being Constitutional Amendment 95, which froze expenditure on health and education for a 20 year period⁹9 Amaral NC. Com a PEC 241/55 (EC 95) haverá prioridade para cumprir as metas do PNE (2014-2024)? Rev. Bras. Educ. 2017; 22(71):1-25.; labor legislation reform, which restricted rights that had been conquered by Brazilian workers¹⁰10 Krein JD. O desmonte dos direitos, as novas configurações do trabalho e o esvaziamento da ação coletiva Consequências da reforma trabalhista. Tempo Social revista de sociologia da USP. 2018; 30(1):77-104.; and the proposal for the reform of social insurance presented to the Brazilian congress in 2019¹¹11 Desproteção, austeridade e mercado na nova reforma da Previdência. Congresso em Foco. 2019. [acesso em 2019 mar 21]. Disponível em: https://congressoemfoco.uol.com.br/opiniao/colunas/desprotecao-austeridade-e-mercado-na-nova-reforma-da-previdencia/.
https://congressoemfoco.uol.com.br/opini... , in a context in which the Brazilian president believes that the rights enshrined in the 1988 Federal Constitution are responsible for the upsurge in unemployment, poverty, and inequality.

Specifically in relation to the ‘health sector,’ the difficulties in achieving SDGs involve historical problems and have been aggravated by the crisis of the cooperative federalism which structures the Brazilian public health system (Sistema Único de Saúde - SUS), affecting states and municipalities which due to budget difficulties restrict investments, stop paying the wages of their workers, and find the lack of new federal resources to be one of the principal obstacles to improving SUS¹²12 Ribeiro JM, Moreira MR. A crise do federalismo cooperativo nas políticas de saúde no Brasil. Saúde debate [internet]. 2016 [acesso em 2019 mar 15]; 40(esp):14-24. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-11042016000500014&lng=pt.
http://www.scielo.br/scielo.php?script=s... ^,1313 Moreira MR, Ribeiro JM, Ouverney AM. Obstáculos políticos à regionalização do SUS: percepções dos secretários municipais de Saúde com assento nas Comissões Intergestores Bipartites. Ciênc. Saúde Colet. [internet]. 2017 [acesso 2019 mar 15]; 22(4):1097-1108. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232017002401097&lng=pt.http://dx.doi.org/10.1590/1413-81232017224.03742017.
http://www.scielo.br/scielo.php?script=s... .

With a national scenario like this and in the absence of a favorable global arrangement, what possibilities does Brazil have of achieving the targets of Agenda 2030? This is the question-problem which gave rise to this article.

Focusing on SDG 3 (‘Good Health and Well-Being’), Brazilian health specialists were asked about the possibility of the country achieving the targets of the 17 SDGs and in a more detailed manner the nine principal targets of SDG 3. These specialists assessed the level of importance of certain measures to fulfill SDG 3, as well as proposing other measures. The connection of the assessment and propositions produced a data set which could be analyzed for public policy recommendations, the discussion of which is the objective of this article.

Methodological aspects

This article were prepared based on the results of the study ‘Perception of Brazilian Health Specialists of SDGs and Agenda 2030,’ carried out in a partnership between the Center of Strategic Studies of Fundação Oswaldo Cruz (CEE/Fiocruz) and researchers from the Department of Social Science from the National School of Public Health (Ensp/Fiocruz) and supported by the Department of Programmatic and Strategic Care of the Secretariat of Health Care, Ministry of Health (Dapes/SAS/MS).

For this study health specialists were considered to be the authors of articles in the field of public health, published in journals indexed in the Web of Science (WoS) database between September 2012 and September 2017. Since the proposal of the study was to discover the perceptions of the directions of Brazil in relation to compliance – or not – with the SDGs and Agenda 2030, it was decided to make the first limitation of the target public, selecting only Brazilians who were the principal authors of each article. The search for ‘Brazilian health specialists’ was directly associated with the production of scientific articles.

For the initial search in WoS, the following ‘field labels’ were used: (i) ‘SU – research areas, for which ‘Public, Environmental & Occupational Health’ was chosen; AND (ii) ‘CU – country/region,’ in which was entered ‘Brazil’ OR ‘Brasil.’ 5568 articles were found in this process.

Vantage Point software was used to organize the articles, which extracted the WoS information and produced an Excel® spreadsheet with the following information: article title; authors; principal author; e-mail; institutional affiliation of principal author; and country. The selection of Brazilian authors happened at this moment which reduced the number of articles to 4948.

In this set the same author could have more than one article selected, which signified that they could be selected more than once. To avoid this, the duplication of the email of the principal authors was identified, excluding repeats and reducing the total to 3943 articles. It was also necessary to check that the selected emails were still valid. For this the program Quick Email Verification was used, resulting in 3842 articles.

An analysis of the abstracts of these articles showed that some referred to basic research and the specific aspects of occupational health, and thus were outside the desired field of studies. These articles were removed, leaving 3287 articles, whose principal authors composed the set of specialists to whom the research instrument was sent.

On 22 January 2018, the 3287 specialists selected – who ten days earlier had received an email from CEE-Fiocruz explaining the study and inviting them to participate – received the research instrument, with a deadline to complete it of ten days (9 February 2018). It is important to highlight that, as it is an electronic instrument, it was possible to create a program which made answering all questions compulsory, since not responding each one prevented its finalization and devolution. With this all questions were able to have the same total number of answers.

884 instruments were returned within the stipulated deadline, which corresponded to around 26.0% of all specialists selected, a rate considered high for research of this type. The responses analyzed in this article refer to these 884 ‘Brazilian health specialists,’ which thus forms its universe.

The instrument responded to by the specialists took as a reference the structure used by the GlobeScan/ SustainAbility Survey (2017), in the research project ‘Evaluating Progress Towards Sustainable Development Goals,’ especially concerning the relationship between SDGs and the adoption of Likert type scales.

The instrument consisted of 20 questions, of which 11 were closed and 9 semi-structured, organized in three parts: 1) Respondent Profile; 2) Agenda 2030 and SDGs; 3) Measures for Complying with SDG 3 Targets.

In parts 1) and 2), certain questions used a Likert type scale as a response, with a variation between 1 and 5, in which 1 signifies ‘very low potential/importance’; 2, ‘low potential/importance’; 3, ‘average potential/importance’; 4, ‘high potential/importance’; and 5, ‘very high potential/importance.’

In this article, charts 2 and 4 use data referring to the results obtained from this scale. To prepare them, it was decided to consolidate the data using an arithmetical mean of the numerical value representing the scales attributed by each of the specialist respondents. In other words: for a determined response, the numerical value of the scale attributed by each author (from 1 to 5, as mentioned above) was added up and the result divided by the total number of specialist respondents (884), which gave a final value expressed in accordance with the original scale.

The answers to the semi-structured questions, the measures which the specialists considered as necessary to achieve each of the nine principal targets of SDG 3, are called here ‘policy recommendations.’ Chart 3 systematizes the recommendations presented by the specialists. As these totaled 1805, they were classified and analyzed using thematic categories. Chart 4 presents the responses of specialists (using the Likert scale referred to above) to the recommendations proposed in the research instrument.

The electronic instrument which specialists answered contained a detailed Term of Free and Clarified Consent (TFCC). The digital programming of the instrument meant that it was sent to respondents after they had agreed with this Term of Consent. Guaranteed in the TFCC were the principles of bioethics referring to beneficence, nonmaleficence, and confidentiality, especially because the professionals who analyzed the data had no access to respondents’ names. Finally, it was explained that responses would be used for the writing of scientific articles such as this. The presentation and discussion of the results will be turned to now.

Results and discussion

Chart 1 presents a brief profile of the 884 specialists who responded to the research instrument, showing that the highest concentration is in the 30-60 age group; with a minimum of 10 years professional experience; medium and high levels of knowledge of SDGs and Agenda 2030; and the perception that SDGs have very high importance for guiding public policies.

However, the principal point refers to the widespread predominance of female respondents, justifying that, from here on, the set of respondents will be referred to in the feminine (where relevant), which as well as respecting the objectivity of the fact, contributes to the struggle for the representativity of gender in Brazilian science, a question rigorously dealt with in a high quality paper by Grossi et al.¹⁴14 Grossi MGR, Borja SDB, Lopes AM, et al. As mulheres praticando ciência no Brasil. Revista Estudos Feministas [internet]. 2016 [acesso em 2019 mar 21]; 24(1):11-30. Disponível em: https://dx.doi.org/10.1590/1805-9584-2016v24n1p11.
https://dx.doi.org/10.1590/1805-9584-201... .

Chart 2 shows the specialists’ perceptions of which SDGs should be priorities for Brazil, the SDG which contributes most to achieving SDG 3 (Health and Welfare) and Brazil’s potential to reach the SDGs.

The first point that should be highlighted in the analysis of chart 2 is that the specialists’ perception of Brazil’s potential to achieve the SDGs is of disbelief: the score of all 17 objectives varies from 2.2 to 2.8, which as explained in the methodological aspects corresponds to the category ‘Low.’

In this context, focusing on SDG 3 (Good Health and Well-Being), it can be seen that for the specialists, this is only the 12th SDG in terms of Brazil’s potential to comply with them, and is only higher than SDGs 8, 11, 16, 10, and 1. In this classification, SDG 6 (clean water and sanitation) and 5 (gender equality) occupy the first place.

It is noteworthy that among the SDGs which the specialists perceived as having the lowest potential to be achieved by Brazil was SDG 1 (no poverty) and 10 (reduced inequalities), social problems for which Brazil, during the first fifteen years of the twenty-first century, implemented an important set of public policies which obtained considerable success, placing the country on a positive trajectory and which pointed to concrete opportunities to achieve the SDGs in question.

Since the research was carried out in 2018, under the impact of fiscal austerity policies and the reduction of state investment; an attack on social protection policies; the publicization of reemergence of inequality, poverty, unemployment, maternal mortality; and the increasing restrictions on democracy, it is considered here that the results discussed above reflect at least in part this problematic scenario. Research to periodically update these results would be an important manner of corroborating or rejecting this conception.

In chart 2 it can be seen that the specialist respondents believed that Brazil should prioritize achieving SDG 4 (Quality Education) and 1 (No Poverty) and that these are also the SDOs which contribute most to reaching SDG 3 (Health and Well-Being). It can be perceived, as mentioned, that SDG 1 is seen as having the lowest potential to be fulfilled, while 4 has the same low potential as SDG 3.

This set of perceptions is in line with the social determinants of health approach, which is reinforced when it can be seen that SDG 8 (decent work) and 2 (zero hunger) also appear among those which should be considered as priorities by Brazil and which most contribute to SDG 3.

Given the gloomy scenario highlighted by the specialists, what factors do they see as preventing SDG 3 from being achieved? This is shown in graph 1.

The analysis of graph 1 shows that the specialists consider, with great emphasis, the ‘bad quality of health administration’ and ‘corruption in the health system’ to be the principal factors, which to a certain extent reveals an unexpected convergence with the common sense, especially because there is little evidence and a lack of studies to scientifically support these relations, above all in relation to corruption in the health system.

On the other hand, it can be considered that a thematic approximation between the responses ‘austerity policies,’ ‘lack of financial resources,’ and ‘excessive financial dependence of states and municipalities on the federal government’ allows an analysis in which the unification of the responses would total 84.3%, which would turn it into the one most cited by the specialists.

Nevertheless, this thematic approximation cannot remove the emphasis given to the ‘bad quality of health administration’ and ‘corruption in the health system,’ much less explain the fact that the ‘lack of financial resources’ received, as an individual response, a very low percentage of responses, lower than one third of respondents.

Thinking about overcoming the difficulties and the direction which Brazil should follow to achieve the SDGs of Agenda 2030, the specialists were asked for measures, policies, and actions to be implemented by the Brazilian public authorities for the country to comply with SDG 3. In this article, these will be treated as ‘policy recommendations’ and detailed in charts 3 and 4.

Chart 3 synthesizes a set of 1805 policy recommendations proposed by the specialists to achieve SDG 3. It should be noted that these recommendations are distributed among the nine Targets of SDG 3 and classified in themes which makes the analysis more feasible and overcomes a ‘large n’ distribution type for open questions.

It should also be taken into account that the recommendations classified in the categories ‘Education’ and ‘Basic Care’ are the principal ones for Targets 3.1; 3.2; 3.3; 3.4; and 3.7. Furthermore, ‘Education’ appears as an important category for Targets 3.5; 3.6; 3.8; and 3.9.

Basically, the category ‘Education’ systematizes a myriad of recommendations which refer in different manners to the Education of the population in relation to the theme to which the SDG Target refers. Importantly, this category does not include the recommendations aimed at the training of professionals for the health system (or areas related to the theme), which were grouped in the ‘Training’ category.

In turn, the ‘Basic Care’ category, which can be understood more automatically, aggregates the recommendations which cover the improvement of services, human resources, organization, funding, etc., related to the Basic Care provided by SUS.

Chart 4 illustrates the perceptions of the specialists in regard to a set of 48 policy recommendations which the Research team believe capable of contributing to achieving the nine targets of SDG 3.

Of the 48 recommendations presented to the specialists, 42 were perceived by them as of ‘high importance’ (as explained in the methodological aspects, on a scale of 4 to 4.9), while 5 were seen as having ‘reasonable importance’ (on a scale between 3 and 3.9); while one had ‘low importance’ (between 2 and 2.9).

It is notable that among the six recommendations perceived as being of ‘reasonable’ or ‘low’ importance by the specialists are: ‘legalization of abortion’ (recommendation to achieve Target 3.1, referring to the reduction in maternal mortality); ‘legalization of marijuana’ and ‘decriminalization of other drugs’ (recommendations for Target 3.5, referring to the prevention of drug abuse), with the latter being the only seen as of ‘low’ importance; and ‘obtain commitments from vehicle manufacturers and hold them responsible’ (recommendation for Target 3.6, referring to the reduction in the number of deaths and injuries from road accidents).

In relation to the recommendations perceived as having ‘high’ importance by the specialists, it should be noted that: i) those which refer to Basic Care appear among the most important, notably Targets 3.1, 3.2, 3.3, 3.7 and 3.8 (in which ‘achieve universal Basic Care cover’ achieves the highest score of all the recommendations: 4,9); and ii) ‘reduce poverty’ appears as the most important for Targets 3.1 and 3.2, and as the second most important for Target 3.3.

Conclusions

The skepticism of the specialists in relation to the possibility of Brazil achieving the SDGs by 2030 points to a negative response to the title/question of this article. The data presented structured the perception that for them the country has a low potential to reach any of the 17 SDGs, especially: no poverty (SDG 1), reduced inequalities (SDO 10), and peace, justice and strong institutions (SDG 16), which aligns this perception with the ‘Spotlight Report on Agenda 2030 for Sustainable Development’¹⁵15 Act!onaid. Grupo de Trabalho da Sociedade Civil para Agenda 2030. Relatório Luz da Agenda 2030 para o desenvolvimento sustentável - Síntese II. [internet]. 2018 [acesso em 2019 mar 21]. Disponível em: http://actionaid.org.br/wpcontent/files_mf/1532366375relatoriosicc81ntese_final_download.pdf.
http://actionaid.org.br/wpcontent/files_... , written by the Civil Society Working Group of Agenda 2030.

Quality education and no poverty, respectively SDG 4 and 1, are seen here as the most important to be reached by Brazil and also the ones which will contribute most to Brazil complying with SDG 3 ‘Good Health and Well-Being,’ a result which opens possibilities for dialogues with the proposed emphasis on the interaction of SDGs and their targets¹⁶16 Moreira MR, Ribeiro JM, Motta CT, et al. Mortalidade por acidentes de transporte de trânsito em adolescentes e jovens, Brasil, 1996-2015: cumpriremos o ODS 3.6? Ciênc. Saúde Colet. [internet]. 2018 [acesso 2019 mar 21]; 23(9):2785-2796. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232018000902785&lng=pt.
http://www.scielo.br/scielo.php?script=s... and with the health proposal in all policies¹⁷17 Buss PM, Fonseca LE, Galvão LAC, et al. Health in all policies in the partnership for sustainable development. Rev Panam Salud Pública. [internet]. 2016 [acesso em 2019 mar 21]; 40(3):186-191. Disponível em: http://iris.paho.org/xmlui/bitstream/handle/123456789/31235/v40n3a7-186-91.pdf?sequence=1&isAllowed=y&ua=1&ua=1.
http://iris.paho.org/xmlui/bitstream/han... .

Education was also very important in relation to achieving the targets of SDG 3 – Health and Well-Being –, since it emerges as an important recommendation to achieve all nine targets, with the most important being the targets related to maternal mortality, Aids, tuberculosis, mental health, drug abuse, road accidents, and sexual and reproductive health.

Less cited than Education, but still very important, the strengthening of Basic Care also emerges as a strong recommendation for the public authorities, above all in relation to child mortality.

Taking into account that the recommendations were proposed by the research instrument and highlighting that it was considered as having the highest potential to fulfill each SDG 3 target, it is possible to present a role of recommendations distributed along two axes: the first related to what can be called ‘social policies’ – i) reduction of poverty; ii) increase in basic sanitation cover; iii) reduction of different manifestations of violence; iv) investment in the quality of public roads and highways; and v) expansion of control over extractive activities and polluting industries – while the second is more directly related to health policy: vi) reach universal Basic Care cover; vii) expand and improve the quality of prenatal care in Basic Care; viii) expand ‘sexual and reproduction health’ in Basic Care; and ix) expand the prevention of alcohol abuse.

References

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