Introduction

The Millennium Development Goals (MDGs) were adopted on a voluntary basis in 2000, by 189 nations.1 Some of the MDGs are fundamental human rights, such as health and education. They are to be achieved by 2015 (see Box 1). Governments have reported regularly on the progress. Several statistical analyses, based on measurable indicators, have been published recently.2, 3 In 2009, UN Secretary-General Ban Ki-Moon4 summarised: ‘Nine years ago, world leaders set far-sighted goals to free a major portion of humanity from the shackles of extreme poverty, hunger, illiteracy and disease. They established targets for achieving gender equality and the empowerment of women, environmental sustainability and a global partnership for development… we have been moving too slowly to meet our goals. And today, we face a global economic crisis whose full repercussions have yet to be felt… Early indications are that, not surprisingly, the poor have suffered most from the upheaval of the past year. The numbers of people going hungry and living in extreme poverty are much larger than they would have been had progress continued uninterrupted.’

The latest published analyses of progress seem to indicate acceleration of the achievement process.5 The global average is dominated by the government-reported overachievement of some countries, especially People's Republic of China. Most of the African countries are lagging behind especially for MDG 5 on maternal mortality.6 We found few reports where the investigators sought the views of involved health professionals working in the field of public health, serving as spokespersons of public health associations, schools of public health or institutes of public health, or working in primary health care or health administration. Adegboye et al found in Niger that 21 per cent of doctors at tertiary health centres had no foreknowledge of the acronym MDG and 42 per cent did not know that there are 8 MDGs.7 The authors conclude ‘that there is an absolute need for more elaborate publicity of the MDGs … if attaining the MDGs is to be a reality’.

The World Federation of Public Health Associations (WFPHA) decided to conduct an online survey to explore the opinions of public health professionals around the globe and their experience with the implementation and achievement of the MDGs, with a focus on sub-Saharan Africa, the region lagging farthest behind.

Methods

The quali-quantitative survey was conceived based on Ulrich Laaser's proposal (personal communication, 2010) and was conducted by WFPHA health professionals in collaboration with the WFPHA Equity Working Group, between January and March 2012. The survey was translated into four languages from the original English version (French, Spanish, Portuguese and Chinese) and published online through <survemonkey.com>. We contacted all public health professionals and organisations (N=5014) listed in the WFPHA database by e-mail between April and July 2012 and invited to complete the survey if they were involved in MDGs-related activities. We also advertised the survey in the WFPHA newsletter, Facebook group, and Twitter. We promoted the survey during the 13th World Congress of Public Health, April 2012 in Addis Ababa, Ethiopia.8 In total, we received 427 completed questionnaires, representing professionals from 71 countries.

The landing page of the online questionnaire is displayed in Figure 1, the complete questionnaire can be found in Appendix. Percentages are rounded; differences are tested by Pearson Chi2.

Figure 1
figure 1

Landing page of the online questionnaire used in the survey. (From https://www.surveymonkey.com/s/MDGs_en, which is no longer online. See the full version in Appendix).

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The questionnaire consisted of the following sections:

  • position/role of respondent (including Public Health Association (PHA) membership)

  • social categories and education

  • professional work

  • importance of MDGs

  • involvement/activities in MDG implementation

  • main challenges/obstacles

  • collaboration and partners

  • support of the work on MDGs

  • achievement of MDGs and

  • usefulness of the survey.

We analysed the results and then subcategorised them according to respondents’ role (individual professionals versus official spokespersons), WHO regions, main countries, and country's Gross National Income (GNI) according to the World Bank Indicators.9

Here we report mainly the results obtained from the quantitative part of the survey. We will analyse the qualitative data separately.

The survey was ranked as ‘Very relevant/useful’ by 55 per cent and ‘somewhat relevant/useful’ by 37 per cent. Two percent of all answers were negative; 6 per cent had no opinion.

Professional experts involved with the implementation of MDGs accounted for 65 per cent of respondents and 18 per cent answered as the official spokesperson of their PHA (Others accounted for 17 per cent).

Figure 2 shows the distribution of answers according to WHO Regions. Although 67 per cent of all completed questionnaires came from the African Region (AFR), the West Pacific Region (WPR) responses constitute 14 per cent, the next highest group of respondents. The response rate from all other regions was low. In AFR and WPR, WFPHA has regional offices in Addis Ababa and Beijing.10 Moreover, 73 per cent of all participants came from low or lower-middle income countries – according to the World Bank Indicators.9

Figure 2
figure 2

Respondents according to WHO regions (rounded percentages). Legend: AFR – African Region; AMR – Region of the Americas; EMR – Eastern Mediterranean Region; EUR – European Region; SEAR – South-East Asia Region; WPR – Western Pacific Region; INT. – International Organisations.

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Results

Of all respondents, 88 per cent had been directly involved in MDGs-related activities, collaborating mainly with the national government (20 per cent), multilateral organisations (17 per cent), local NGOs (15 per cent), and local communities as well as bilateral agencies (13 per cent each). 80 per cent of the respondents were still working in the area, mainly focusing on maternal and child health (24 per cent), communicable diseases (20 per cent), and public health professionals’ education (10 per cent). Sixty-three per cent acted as supporting partners in MDGs-related activities. Those not yet involved (12 per cent), indicated that they were interested, but up to now had no opportunity, for example, if their PHA had only recently started. Almost all required support (90 per cent): 26 per cent financial support; 20 per cent logistic/organisational support; 20 per cent technical consultancy; and 17 per cent supportive advocacy.

Figure 3 shows in what MDGs the respondents were principally involved – most in the directly health related MDGs 4, 5, and 6 with a frequency of 20, 22, and 23 per cent, respectively. The answers did not differ significantly between professional experts and spokespersons (N=839 and 194; P=0.935), nor between the two regions with the highest number of answers – the AFR and the WPR (N=867 and 135; P=0.152) nor within the countries with the highest number of answers (Ethiopia and China, N=671 and 79) and their region (AFR and WPR without Ethiopia or China, N=196 and 56; P=0.672, and 0.250, respectively). This applies also if respondents’ countries of origin were ranked according to the World Bank Indicators low, lower-middle, upper-middle, and high-income countries (LIC, LMIC, UMIC, HIC, respectively; N=165, 121, 154, 776; P=0.136).

Figure 3
figure 3

Main expert involvement according to MDGs (multiple answers possible, rounded percentages).

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Figure 4 presents the overall opinion about the importance of the 8 MDGs. Besides the classical health related MDGs 4, 5, and 6, only MDG 1 was identified as the most relevant MDG by a higher percentage of respondents (16 per cent). All the 8 MDGs were considered relevant by at least some in the public health community (N=1381). There is no significant difference between professional experts and official spokespersons (N=900 and 254; P=0.657). The importance given to the different MDGs was, however, significantly different among the regions, that is, MDG 7 and 8 are more important for China (N=114) and WPR without China (N=57) than in Ethiopia (N=703) or in AFR without Ethiopia (N=259) while we see the opposite if we consider MDG 4 and 5 (P < 0.001). Furthermore, significant differences can be observed according to the World Bank classification (P < 0.001): respondents from poor countries are ranking MDG 1 higher, but not MDGs 7 and 8, whereas the opposite is true for the higher income countries (data not shown).

Figure 4
figure 4

MDGs considered being of highest importance in participants’ countries (multiple answers possible, rounded percentages).

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A comparison between the ranking by importance in Figure 4 and the real involvement of respondents in MDGs-related activities (Figure 3) reveals highly significant differences. The professional involvement does not match the perceived importance of MDG 1 in the LIC (6.6 versus 20.2 per cent) as well as in the LMIC (5.2 versus 11.3 per cent; P < 0.001 and P=0.028 on all 8 MDGs compared respectively; data not shown). In the UMIC and HIC especially high weights were given for the importance of MDG 7 (24.2 versus 12.4 and 18.2 versus 5.5 per cent; P=0.012 and P=0.001 on all 8 MDGs respectively; data not shown) and 8 (UIMC only) as well. Most of the respondents were involved in services/programmes under MDG 4 and 5 across all GNI country groups. MDG 6 remains of high importance as well as the focus of many activities for almost all GNI country groups (see detail Table 1).

Table 1 Comparison of assigned importance and main involvement of respondents according to World Bank Indicators (multiple answers possible, rounded percentages, maxima bolded)
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All respondents together listed as challenges or obstacles encountered most frequently the economic crisis and the lack of in-country resources (11 per cent each). Geographical limitations were mentioned nearly as frequently, together with the unavailability of primary health care services and cultural reasons (10 per cent each). Lack of local coordination and organization, lack of sufficient human resources within the PHA/Organization, lack of logistic support, political reasons, and lack of international cooperation financial and/or technical support were mentioned less frequently. We present selected statements in Box 2.

Altogether 51 per cent agreed fully and 40 per cent partially with the statement that ‘In your/your Public Health Association/Organization’s opinion, the MDG related activities undertaken by you/your Public Health Association/Organization achieved their desired/expected results (were they successful)?’. Only 6 per cent disagreed, 3 per cent had no opinion.

Discussion

In this survey, public health professionals clearly pointed out that they are mainly involved in their day-to-day activities in MDGs 4, 5, and 6. They declared positive experiences with the implementation of these goals. The positive motivation of the public health workforce is an invaluable achievement in itself. Public health professionals work with energy and enthusiasm on those of the MDGs they are able to influence, mainly 4, 5, and 6, knowing at the same time that the underlying causes addressed in MDG 1, 2, 3 and to some degree 7, are not under their direct influence. The qualitative aspects of survey reported Box 2 show that the notion of basic values, fairness, and human rights to be present among the participants. The link between actions for some MDGs and the fulfilment of others seems to be missing. Understanding of MDG 8 among public health professionals was limited and does not include the notion of negative duty, meaning that we are responsible for the global misery.11

In this study we were more interested in the experiences of the involved public health workforce, less in the statistics of achievement. The degree to which the concept of MDGs has been transmitted to the actors in the field is related to the MDGs’ success. In spite of the limitations of our study, our results shed light on some issues that are especially relevant for designing the next generation of MDGs after 2015, whatever they will be called. Nevertheless our study has several intrinsic limitations that have to be considered in the interpretation of the results:

  1. 1)

    The respondents do not constitute a statistically representative sample; only 22 of 80 WFPHA member associations (28 per cent) answered the questionnaire. For sub-Saharan Africa, the number of completed questionnaires was quite high (N=291). Furthermore, 88 per cent of the responding experts indicated a direct involvement into MDGs-related activities. Despite self-selection in a non-representative sample, we found considerable homogeneity: involvement in MDG activities does not differ significantly across the various sub-groups.

  2. 2)

    The respondents answered according to their personal knowledge and their subjective opinions. We intended in order to complement the published statistical analyses of MDGs with personal experience and qualifying statements. A more representative approach would require much greater resources, but we recommend it be done before 2015. As 92 per cent of respondents judged the survey as very useful or somewhat useful, we conclude that our approach, to ask for personal experiences, was welcome, because it filled a gap not yet covered.

  3. 3)

    The questionnaire was oriented predominantly to the past experience of the target group, but did include information about experts’ involvement in on-going activities. A subsequent questionnaire, focusing the on-going activities and future development, will make use of the present results. Analysing the past comprehensively is a precondition for developing the future: ‘Those who cannot remember the past are condemned to repeat it’.12

One key feature of our analysis is the significant variance of the importance assigned to single MDGs. Although all the 8 MDGs were considered by at least some in the public health community to be relevant, in the African Region the classical health related MDGs 4 and 5 received highest relevance scores, whereas in the Western Pacific MDGs 7 and 8 on environmental sustainability and global partnership were considered most important. (MDG 6 was of high importance for both regions). This may well indicate the most immediate threats in the respective regions. Correspondingly MDG 1 on poverty reduction was valued significantly higher in the LIC than in the UMIC and HIC. This discrepancy in perceived importance versus activities exists also for MDG7 that received awareness in higher income countries, but only sparse activity was deployed in the field.

The main barriers in working on MDGs were listed as financial resources, communication infrastructure including access to primary health care, and interestingly cultural reasons. These findings might well be considered in the design of a next round of development goals.

Key messages

The overwhelming majority of public health professionals approves the MDGs and looks with optimism on their achievability in spite of considerable challenges. The regional differences in assigned importance should be considered in the next round of development goals.