Healthcare Managers’ Perception About the Sustainable Development Goals (SDGs)

In 2015, about 190 United Nations Member States proposed an ambitious agenda, to be worked on by different actors in society, which was entitled 2030 Agenda. The document was divided into 17 Sustainable Development Goals (SDGs), which are broken down into 169 targets aiming to eradicate poverty and promote a decent life for all. This study aimed to evaluate the perception of healthcare managers about SDGs, especially SDG 3, which addresses Good Health and Well-Being. This cross-sectional observational study identified and analyzed the participants’ profiles through online forms with questions about the general perception of the SDGs, and questions related to SDG 3. The quantitative analysis of the results was performed, in percentage terms, and the qualitative analysis was performed using the five-point Likert scale. Twenty-one technical directors of healthcare services participated in the survey. According to the results, 14 (66.6) of the participants presented medium to high knowledge regarding SDG. In addition, 18 (85.7%) of these professionals understand that the SDGs are of high/very high importance to guide public policies. In general, there is a low expectation for the achievement of the 17 SDGs in Brazil, but it was highlighted that it should be a priority, which SDG could contribute to the achievement of SDG 3: Good Health and well-being as well as the vision of policy recommendations to achieve the SDG 3 targets. This analysis allows contact with SDG and enables a deeper discussion on the topic in healthcare services.


Introduction
The United Nations Conference on Environment and Development, Rio-92, was a historic event in which the most important global environmental agreements in history were signed, highlighting the Agenda 21, which consisted of a global scale action program aiming to put into practice the concept of sustainable development through the rational use of resources without hindering economic development.
In 2000, in a continuous effort to achieve sustainable development, the United Nations (UN) organized the Millennium Summit in New York City. From the discussions at the event, 8 priority goals were set to be achieved by 2015, with a focus on developing countries. These goals are known as the Millennium Development Goals (MDGs). development with a win-win cooperation. The 17 Sustainable Development Goals are: (1) No Poverty; (2) Zero Hunger; (3) Good Health and Well-being; (4) Quality Education; (5) Gender Equality; (6) Clean Water and Sanitation; (7) Affordable and Clean Energy; (8) Decent Work and Economic Growth; (9) Industry, Innovation and Infrastructure; (10) Reducing Inequality; (11) Sustainable Cities and Communities; (12) Responsible Consumption and Production; (13) Climate Action; (14) Life Below Water; (15) Life On Land; (16) Peace, Justice, and Strong Institutions; (17) Partnerships for the Goals.
According to Ban Ki-moon, United Nations Secretary-General: "Business is a vital partner in achieving the Sustainable Development Goals. Companies can contribute through their core activities, and we ask companies everywhere to assess their impact, set ambitious goals, and communicate transparently" (SDG Compass, 2015). Thus, there is an excellent opportunity for companies to demonstrate how their businesses can contribute to people and the planet. Moreira et al. (2019) highlight that, despite the ambition of the SDGs and the global dimension, the political strategy for implementation is national and there is a need for the participation of various agents, including large corporations.
The Millennium Development Goals (MDGs) have expanded access to healthcare, but there is a need to act on the quality of patient care to achieve the SDGs. It is very challenging to establish representative health indicators related to the SDGs (Kruk, 2017;Murray, 2015;Alleyne, 2015). Rasanthan (2016) highlights the need to act on health inequities and social determinants of health to achieve the SDGs. Wesley (2016) addresses the importance of peace and, consequently, of SDG 16: "Peace, Justice and Strong Institutions" for the achievement of SDG 3: "Good Health and Well-being" exemplifying how the issue of refugee immigrants increases poverty and, consequently, health inequities. Vieira (2020) analyzes the financing of the Public Health System (SUS) between 2010 and 2019 in Brazil and concludes that there is a high risk of failure in achieving SDG 3 goals. Nevertheless, some initiatives related to the SDGs are already observed in the Brazilian healthcare sector, such as the Oswaldo Cruz German Hospital, which brings in its 2019 Sustainability Report the actions developed by the Institution related to SDGs. The Paulista Associaton for Medicine Development (SPDM), one of the largest Social Health Organizations in Brazil, started in 2020, the use of the SDG logos in its internal communication channels and defined a Strategic Goal for 2021 to promote affirmative actions to support the Sustainable Development Goals (SDGs) through leadership training, among other actions. The Albert Einstein Israelite Hospital has been using the SDGs as a reference since 2015 in its Sustainability Plan and defined 11 more significant SDGs for their business.
It is noticed that there is already a growing movement to use the SDGs in the Healthcare Services strategies, wherein performance can permeate several SDGs, with emphasis on the SDG 3: Health and Well-being, which brings bold goals related to the reduction of diseases, mortality, access to health and medicines, among others.
A report by Pan American Health Organization (PAHO) on Sustainable Development Goals brings global data related to SDG 3, highlighting 303,000 women who died from complications in pregnancy and childbirth in 2015, almost all of which occurred in low-income countries and middle income; around 800,000 suicide deaths occurred in 2016, with the highest rate in the European Region (15.4 per 100,000 inhabitants); road traffic injury deaths have increased since 2000, reaching 1.25 million in 2013; at least half of the world's population does not have full access of essential health services; in 2016, outdoor air pollution in cities and rural areas caused around 4.2 million deaths worldwide and unsafe water, sanitation, and poor hygiene were responsible for around 870,000 deaths in 2016.
Considering these data, the representativeness of the healthcare sector, and its permeability related to the SDGs, do healthcare managers know, value, and believe in the potential of SDGs for Brazil to move forward with these topics? Thus, this study aimed to evaluate the perception of Healthcare Managers about SDGs, particularly SDG 3: good health and well-being being a relevant tool for diagnosis and expanding the interest on the subject for healthcare services.

Method
This is a qualitative and quantitative cross-sectional observational study to evaluate the healthcare managers` perception regarding the SDGs. The survey tool was approved by the Superintendence of SPDM Affiliated Institutions-São Paulo State Association for Medicine Development, a private non-profit entity, qualified as a Social Health Organization. The organization is responsible for managing several healthcare and education services located in São Paulo and Minas Gerais states, in Brazil.

Research Ethics Committee of the Federal University of São Paulo (CEP/UNIFESP).
For this research, it was defined that healthcare managers are technical directors of healthcare services managed by SPDM Affiliated Institutions.
The survey form was sent to Technical Directors, by e-mail, through the Superintendence of SPDM Affiliated Institutions. The survey was available for ten days, from 03/03/2021 to 03/12/2021. The Informed Consent Form was an integral part of the questionnaire and participation was only possible after ticking the "I agree" option at the beginning of the research. At the time the survey was conducted, the organization had 29 professionals with this profile.
The survey consisted of an online form (Forms Office) elaborated with questions based on the article by Moreira et al. (2020) and in the Globescan/SustainAbility Survey (2017) and designed by the authors for application to healthcare managers. The online form was divided as follows: • Introduction to the SDGs, the reason for the research, and the reference used for the development of the questions. A link to a website with access to the 17 SDGs and the 169 targets was also included, so if needed, the participants could consult it while filling the form.
• 7 questions for identification and profile analysis of participants.
• 5 questions about the general perception of SDGs (knowledge on the subject; the importance of the SDGs to guide public policies; SDGs that should be a priority for Brazil; SDGs that would most contribute to the achievement of SDG 3-Good Health and well-being; Brazil's potential to comply with the SDGs. • 9 questions about the SDG 3 targets (3.1 a 3.9). These questions aimed to evaluate the participants' perception of 48 policy recommendations presented in research used as the basis for this work (Moreira et al., 2020) understood as capable of contributing to the achievement of SDG 3 targets. The original form is available in Portuguese at the link: https://forms.office.com/Pages/ShareFormPage.aspx?id=i-XNIdmBA0ex5GEJObgvGRvYhjxGo9tDrgBcFD3V7 qxURUlNV1lVM1hIOTdHVk8xNFdCVVhOTVNIMy4u&sharetoken=DFeqZi9UlQjmRrnTN6jr The online forms responded by the participants generated a database in Excel format. Quantitative analysis of the results was performed, in percentage terms. Qualitative analysis was performed using the five-point Likert scale.
A Likert scale is a qualitative tool widely used in research to assess the agreement degree about a topic (Silva Júnior, 2014). In this study, the five-point Likert scale was used. The calculation was made using the arithmetic mean of the answers (sum of the answered values/number of answers) and the values obtained were classified according to (Moreira et al., 2020) presented in Table 1. Table 1. Rating of responses using the five-point Likert scale.

Score on the five-point scale
Rating based on the arithmetic mean of the answers Degree of importance/potential 1 1−1.9 Very low 2 2-2.9 Low 3 3-3.9 Medium 4 4-4.9 High 5 5 Very high

Results
When analyzing the participants' profile in   (Table 3). Regarding the "SDGs that should be a priority for Brazil" shown in Table 4, SDG 4-Quality Education was presented by 16 (76.2%) participants, followed by reduction of inequalities by 7 (33.3%) and SDG 1-No poverty; SDG 2-Zero hunger; SDG 3-Good Health and well-being; SDG 6-Clean water and sanitation each one with 6 (28.6%) responses.  2) The number of answers considered for this question was 20 (n=20) because one of the participants checked more than three options and his answer was canceled.
When analyzing the perception of which SDGs, if achieved, would bring greater contribution to achieving SDG 3: Good Health and well-being, SDG 6-Clean water and sanitation was mentioned by 17 (81.0%) participants, followed by SDG 4-Quality Education with 15 (71.4%) and SDG 1-No poverty by 11 (52.4%) participants (Table 5). The Likert Scale was used to analyze the participants' perception of Brazil's potential to achieve each of the 17 SDGs. There is a low expectation of healthcare managers to achieve the SDGs, with the average values ranging from 1.8 to 3.0 (very low to medium) (  The answers presented in Table 7 refer to the participants' perception of policy recommendations considered capable of contributing to the achievement of the targets of SDG 3 (targets 3.1 to 3.9). The table brings the targets as well the policy recommendations referring to each one, with a total of 48 recommendations, evaluated using the five-point Likert scale.
The average of the participants' responses shows that 37 (77.0%) of the 48 policy recommendations were classified as "high important" by the Likert scale methodology used (value between 4 and 4.9); 9 (18.8%) as "medium importance" (value between 3 and 3.9) and only 2 (4.2%) as "low importance" (value between 2 and 2.9).

-By 2020, halve the number of global deaths and injuries from road traffic accidents
Compromise and hold manufacturers of automotive vehicles 3.3 Increase the obligation of security items for automobile fleets in Brazil 3.9 Expand urban mobility policies that encourage the use of public transport 4.0 Implement the Dry Law throughout the national territory 4.3 Regulate advertising for car sales so as not to encourage aggressive driving 3.1 Investing in the quality of public roads and highways 4.3 Target 3.7 -By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes Incorporate discussions about gender, sexuality, misogyny, sexism, homophobia and preconception in schools 3.6 Expand education and mass communication actions 4.3 Implement specific policies for adolescents linked to sports, education, culture and others that incorporate education on sexual and reproductive health 4.6 Achieve universal coverage of primary care with sexual health and reproductive health components 4.4 Target 3.8 -Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all Expand the popular pharmacy network 4.1 Expand free drug distribution 4.1 Expand public social protection policies, such as income transfer, housing and education 4.0 Improve the mechanisms for regulating access to hospital and highly complex services in the public and private spheres 4.2 Achieve universal coverage of Primary Care 4.6 Target 3.9 -By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination Expand policies to encourage organic farming and family farming 4.2 Expand protection for workers exposed to occupational risk 4.3 Expand the use of clean and renewable energy 4.4 Increase control over pesticide use 4.5 Expand control over extraction activities and polluting industries 4.5

Discussion and Conclusion
First, it is important to emphasize that the period where in the online survey was carried out coincided with a very critical period of the COVID-19 Pandemic. During that time there was a significant increase in the number of cases and, consequently, the occupation of hospital beds. Due to the profile of participants this could have made it difficultfor them to answering the questionnaire. Either way, the survey received responses from 21 technical directors of 29 professionals with this position in the organization, representing 72.4% of the total.
Despite the research having had a relatively small number of participants, the knowledge of these professionals stands out, in which 16 (76.2%) have over 20 years of professional experience in the Healthcare Sector.
The importance of the participation of different sectors of society in the attempt to achieve the SDGs by the year 2030 is also highlighted, and the topic must be known to all. In this research, it was found that the level of knowledge of participants in leadership positions in healthcare service on the topic SDG/2030 Agenda was from medium to high for 14 (66.6%) respondents. It is understood that more effective communication is needed to disseminate the SDGs, considering that Brazil has committed to the 2030 Agenda. In addition, 18 (85.7%) of these professionals understand that the SDGs are of high/very high importance to guide public policies.
In comparison to the research developed by Moreira et al. (2020) which was the basis for this work and evaluated the perception of healthcare specialists on the SDGs, defined as authors of articles in the field of public health, published in indexed journals, the results of knowledge on SDGs/2030 Agenda had answers, on the same scale, with a predominance (59.4%) of the answer "medium to high knowledge". Likewise, for comparison purposes, 80.8% of the participants in the survey conducted by Moreira et al. (2020) understand that the SDGs are of high/very high importance to guide public policies.
In general terms, compared to the referred research, the values and perceptions were very similar, even considering other professional profiles of Healthcare and considering the fact the survey was conducted in 2018 and with a more comprehensive sample (884 participants). In the analysis of the results, it was verified that these two questions could have been worked on by the five-point Likert scale and this change is recommended in future works.
Regarding the SDGs that should be prioritized by Brazil, the most relevant theme, presented by 16 (76.2%) participants were SDG 4-Quality Education, followed by SDG 10-Reducing Inequality presented by 7 (33.3%) participants. Other themes perceived as priorities by 6 (28.6%) participants were: SDG 1-No poverty; SDG 2-Zero hunger; SDG 3-Good Health and well-being; SDG 6-Clean water and sanitation. In general, the themes highlighted by the participants reveal Brazil's social problems, which are being intensified with the evolution of the COVID-19 Pandemic in 2020 and 2021.
In comparison with the study by Moreira et al. (2020), the six relevant themes that should be priorities for Brazil, the only one that appears different from this study is SDG 8-Decent employment and economic growth, which appears in place of SDG 10-Reducing inequalities. In addition, in the comparative study, SDG 4-Quality Education is highlighted for 68.6% of the participants' responses. So, we can observe that there is a high similarity in the understanding of the SDGs that should be a priority for Brazil when comparing the two studies.
The question that brings up the "SDGs that would most contribute to SDG 3-Good Health and well-being", SDG 6-Clean water and sanitation was mentioned by 17 (81.0%) participants, followed by SDG 4-Quality Education by 15 (71.4%) and SDG 1-Eradication of poverty by 11 (52.4%) participants. Other themes appear in a more distributed way. These same themes appear in the first positions of the research conducted by Moreira et al. (2020), however, in the following order: SDG 4, SDG 1, and SDG 6.
The perception of healthcare managers and healthcare researchers about the importance of SDG 6-Clean water and sanitation for the lack of sanitation may reflect the quality of life and health of the population, the example of waterborne diseases.
As to the "Potential of Brazil to achieve the SDGs", the participants answered each SDG using the five-point Likert scale (1-very low potential to 5-very high potential) and, in general, there is a low expectation in healthcare managers in regards the achievement of the SDGs with the average of values ranging from 1.8 to 3.0. When discussed the SDGs with the greatest potential for achievement, was mentioned the SDG 5-Gender equality, which may be related to the growing discussions on the female representation and the feminist movement for equal rights, and SDG 17-Partnerships for the goals, that may be related understanding the potential of joint actions involving different sectors of society in achieving the SDGs. On the other hand, SDG 1-Eradication of poverty is perceived as having less potential for achievement. Data on the increase in unemployment and, consequently, of people in vulnerable situations due to the COVID-19 Pandemic in 2020 and 2021 may have contributed to this response from the participants. Finally, it is interesting to observe that SDG 3-Good Health and well-being, one of the objects of this study, appears in 9th place with the potential to be reached by Brazil with the same value as SDG 2-Zero Hunger.
to 2.8, fitting all SDG as "low potential" for the achievement of Brazil. The three SDGs with greater potential for achievement, in the view of healthcare researchers (comparative study), were: SDG 6-Clean water and sanitation, followed by SDG 5-Gender equality, and SDG 17-Partnerships for the goals. On the other hand, SDG 3-Good Health and well-being, appears in 12th place in terms of potential to be reached by Brazil in the comparative study.
The questions that address the perception of participants on 48 policy recommendations capable of contributing to the achievement of SDG 3 targets-Good Health and well-being, the results show that 37 recommendations were classified as "high importance" by five-point Likert scale methodology, 9 recommendations were classified as "medium importance" and only 2 recommendations, related to the issue of drug legalization and discrimination, were classified as "low importance".
Similarly, the research by Moreira et al. (2020), states that from 48 recommendations presented to the respondents, 42 were perceived as "high importance", 5 as "medium importance" and 1 as "low importance". The less value was applied to those related to legalization and drug decriminalization.
The understanding of the policy recommendations presented as high importance by healthcare managers can guide and encourage actions to be developed within the scope of Healthcare Services aimed at achieving the SDG 3 targets, such as programs and campaigns aimed at prenatal care; sex education; prevention of diseases; healthy food; traffic education; lifestyle-related health promotion; abuse of tobacco, alcohol, and drugs; discussions on inclusion and diversity, among others.
This research can be extended to other healthcare service managers to evaluate the professionals' perception, raise awareness about the importance of this topic and foster this discussion in the Healthcare Sector.