key: cord-0791900-dbwlpb5r authors: nan title: NCD Countdown 2030: pathways to achieving Sustainable Development Goal target 3.4 date: 2020-09-03 journal: Lancet DOI: 10.1016/s0140-6736(20)31761-x sha: 0d83d85720bac275a2c0dd901c9437a4c5ebd8fd doc_id: 791900 cord_uid: dbwlpb5r The Sustainable Development Goal (SDG) target 3.4 is to reduce premature mortality from non-communicable diseases (NCDs) by a third by 2030 relative to 2015 levels, and to promote mental health and wellbeing. We used data on cause-specific mortality to characterise the risk and trends in NCD mortality in each country and evaluate combinations of reductions in NCD causes of death that can achieve SDG target 3.4. Among NCDs, ischaemic heart disease is responsible for the highest risk of premature death in more than half of all countries for women, and more than three-quarters for men. However, stroke, other cardiovascular diseases, and some cancers are associated with a similar risk, and in many countries, a higher risk of premature death than ischaemic heart disease. Although premature mortality from NCDs is declining in most countries, for most the pace of change is too slow to achieve SDG target 3.4. To investigate the options available to each country for achieving SDG target 3.4, we considered different scenarios, each representing a combination of fast (annual rate achieved by the tenth best performing percentile of all countries) and average (median of all countries) declines in risk of premature death from NCDs. Pathways analysis shows that every country has options for achieving SDG target 3.4. No country could achieve the target by addressing a single disease. In at least half the countries, achieving the target requires improvements in the rate of decline in at least five causes for women and in at least seven causes for men to the same rate achieved by the tenth best performing percentile of all countries. Tobacco and alcohol control and effective health-system interventions—including hypertension and diabetes treatment; primary and secondary cardiovascular disease prevention in high-risk individuals; low-dose inhaled corticosteroids and bronchodilators for asthma and chronic obstructive pulmonary disease; treatment of acute cardiovascular diseases, diabetes complications, and exacerbations of asthma and chronic obstructive pulmonary disease; and effective cancer screening and treatment—will reduce NCD causes of death necessary to achieve SDG target 3.4 in most countries. Non-communicable diseases (NCDs) are the leading cause of death and ill health and account for seven of ten deaths worldwide. [1] [2] [3] NCDs are included in the Sustainable Development Goals (SDGs) with the following target: "by 2030 reduce by one third [relative to 2015 levels] premature mortality from NCDs through prevention and treatment and promote mental health and well-being" (SDG target 3.4). 4 NCD Countdown 2030 is an independent collaboration to inform policies, track progress, and enhance accountability towards reducing the burden of NCDs. The first paper from NCD Countdown 2030 showed that low-income and middle-income countries, especially in sub-Saharan Africa, and, for men, in central Asia and eastern Europe, had the highest risks of dying from NCDs. 3 The paper also showed that progress is too slow to achieve the target in most countries. The results informed discussions at the third High-Level Meeting on NCDs at the UN General Assembly in 2018, but led to questions about how to accelerate progress in reducing NCDs. This Health Policy paper focuses on identifying those pathways through which each country can achieve SDG target 3.4 to support governments and donors in prioritising resources and interventions in their national NCD response. Although SDG target 3.4 specifies an overall reduction in NCD mortality by a third, there are differences across countries in the risk of dying from different NCDs. 5 This diversity suggests that countries might need to take different routes towards achieving SDG target 3.4 by addressing different combinations of diseases. To identify country-specific options, in this Health Policy paper, we evaluate combinations of feasible reductions in specific NCDs, based on real experiences of some countries, that can achieve SDG target 3.4 in each country. The indicator used to measure progress towards SDG target 3.4 is the cumulative probability of dying from four NCDs (cancers, cardiovascular diseases, chronic respiratory diseases, and diabetes; referred to as NCD4 hereafter) between exactly 30 years and exactly 70 years of age. The probability of death is calculated in the absence of competing causes of death (ie, causes other than NCD4) so that only the risk of dying from these NCDs is measured. For the pathways analysis, we used data from the 2016 WHO Global Health Estimates on age, sex, and causespecific mortality for 176 countries and territories with a population of 200 000 or more in 2016. The data sources and methods for the WHO Global Health Estimates are described in detail elsewhere, 1 and are summarised in the appendix (pp 3-7). Appendix figure 1 (pp 13-15) maps the probability of dying from NCD4 between 30 years and 70 years of age in 2015, which is the base year for measuring progress towards SDGs. Globally, the lowest risk of NCD4 mortality was seen in high-income countries in Asia-Pacific, western Europe, Australasia, and Canada. The highest risk of dying from NCD4 was observed in lowincome and middle-income countries, especially in sub-Saharan Africa, and, for men, in central Asia and eastern Europe. For women, the probability of dying from NCD4 between 30 years and 70 years of age was less than 6% in South Korea and Japan; it was also low in some highincome countries in western Europe (eg, Spain and Switzerland), Singapore, and Australia. The highest probabilities for women were seen in parts of sub-Saharan Africa (eg, Sierra Leone and Côte d'Ivoire), and in Guyana, Yemen, Afghanistan, and Papua New Guinea, where 30-year-old women had a one-in-four to one-inthree risk of dying from NCD4 before reaching their 70th birthday-about three-times to seven-times more likely than in low-mortality, high-income countries. For men, the probability of dying from NCD4 was highest in central Asia (eg, Mongolia and Kazakhstan), eastern Europe (eg, Russia and Belarus), parts of Oceania (eg, Fiji and Papua New Guinea), North Korea, and Yemen, with 30-year old men having a more than one-inthree risk of dying from an NCD4 before their 70th birthday. The lowest probabilities, ranging from 10% to 12%, were those in some high-income countries in western Europe (eg, Iceland and Switzerland), Bahrain, South Korea, Australia, Japan, Canada, New Zealand, and Singapore. Individual or clusters of causes of death (referred to as causes of death hereafter) for analysing reduction pathways in NCD mortality were selected if they were one of ten leading causes of death in either women or men, and for either NCD4 between 30 years and 70 years of age, or for all NCDs plus suicide between birth and 80 years of age. The ranking of causes of death was based on the average across countries of the probability of dying from each cause of death. This process led to the selection of the following 15 causes of death for NCD4: diabetes, chronic respiratory diseases, ischaemic heart disease, ischaemic stroke, haemorrhagic stroke, other cardiovascular diseases, upper aerodigestive tract can cers, lung cancer, stomach cancer, colorectal cancer, liver cancer, breast cancer, cervix uteri cancer, prostate cancer, and other cancers. Two causes (breast and cervical cancer) were only applicable to women and one (prostate cancer) only to men. Additional causes of death for the analysis of all NCDs plus suicide were: liver cirrhosis; kidney and other genitourinary diseases; neurological conditions; mental and substance-use disorders and suicide (SDG target 3.4 uses deaths from suicide as a tracer condition for mental health); and other NCDs. Other NCDs include endocrine, blood, and immune disorders; digestive and genitourinary diseases (except those listed separately); congenital anomalies; and sense organ, skin, musculoskeletal, and oral and dental conditions. Figure 1 shows the probability of dying between 30 years and 70 years of age from NCD4 causes of death in 2015 for 176 countries. Ischaemic heart disease was the leading NCD4 cause of death in people aged between 30 and 70 years in 146 (83·0%) countries for men and 98 (55·7%) for women. The highest risk of a 30-year-old dying from ischaemic heart disease before their 70th birthday was seen in eastern Europe, central Asia, the Middle East and north Africa, and south Asia. For men, the risk reached as high as 20% and for women as high as 13% in some countries. Other causes that occupied the leading position in at least one country and sex were diabetes ( Malawi ( The risk of dying between 30 years and 70 years of age from NCD4 causes of death was greater for men than for women in most countries, except for diabetes (appendix pp [16] [17] . Additionally, women had a higher probability of dying from ischaemic stroke and the aggregate group of other cardiovascular diseases than men in many countries in sub-Saharan Africa, central Asia, the Middle East and north Africa. Based on 2010-16 trends, women in 17 of 176 (9·7%) countries and men in 15 of 176 (8·5%) countries are expected to achieve SDG target 3.4, a third reduction relative to 2015 levels in the probability of dying from NCD4 between 30 years and 70 years of age (appendix pp [18] [19] [20] . Among high-income countries, men and women in Denmark, Luxembourg, New Zealand, Norway, Singapore, and South Korea are on track to meet the target if these countries maintain or surpass their ( Figure 1 continues on next page) 2010-16 average rate of decline; men in Finland and Iceland are also on track. The risk of dying prematurely from NCD4 is also declining rapidly in central and eastern Europe, from very high risk in men, with some countries in this region on track to achieve a third reduction by 2030 (men and women in Belarus; men in Czech Republic and Slovakia; women in Bosnia and Herzegovina, Latvia, Russia, Serbia, and Ukraine). NCD4 mortality among men and women in Iran, Kazakhstan, and the Maldives is declining fast enough to achieve the target of a third reduction by 2030. Women in Kuwait and Timor-Leste and men in Bahrain are also on track. A further eight (4·5%) countries for women and six (3·4%) for men, mostly in central and eastern Europe, are expected to narrowly miss the target of a third reduction. If trends from 2010-16 continue, women and men in China and India, the two largest countries in the world, will have 4-15% reductions in the risk of premature death from NCD4 by 2030, which is not sufficient to meet SDG target 3.4. At the other extreme, the probability of dying from NCD4 between 30 years and 70 years of age has stagnated or increased from 2010 to 2016 among women in 14 (8·0%) countries and men in 20 (11·4%) countries. These countries were in different regions, with the largest number in Africa. Large countries (with sex-specific populations of 10 million or more in 2015) that showed stagnation or small increases in mortality were Bangladesh Estonia (1) The colour of text for each country indicates a region (for a list of countries in each region see appendix p 43). The number in parentheses following each country's name indicates the quality of its vital registration system: 1=high, 2=medium, 3=low, and 4=very low. 2,3 See appendix pp 29-30 for results on all non-communicable diseases plus suicide between birth and 80 years of age. NCD4=four non-communicable diseases including cancers, cardiovascular diseases, chronic respiratory diseases, and diabetes. (men), Egypt (women), Ghana (men and women), Côte d'Ivoire (men and women), Kenya (men and women), Mexico (men), Sri Lanka (women), Tanzania (men), and the USA (women). Even when the probability of dying from NCDs decreases, the number of deaths from NCDs might continue to increase because of changes in population size and age structure. For example, from 2010 to 2016, the number of deaths from NCD4 in those aged between 30 and 70 years increased from 11·2 million to 12·6 million globally, even though the probability of dying in this age range declined in most countries. Trends in the risk of death from 2010 to 2016 varied considerably among NCD4 causes of death (figure 2). The risk of dying from ischaemic and haemorrhagic stroke, ischaemic heart disease, chronic respiratory diseases, and stomach cancer declined faster than that of other causes. By con trast, diabetes, colorectal cancer, liver cancer, breast cancer, prostate cancer, and the residual group of other cancers declined more slowly than other causes, as did lung cancer among women. For every NCD4 cause of death, except ischaemic and haemorrhagic stroke in women, at least 10% of countries had an increase in probability of premature death. For lung cancer in women, and colorectal, liver, and prostate cancers in men, the probability of premature death increased in more than half the countries. The median annual rate of change in the probability of dying prematurely from various causes ranged from +0·2% per year for lung cancer to -2·5% per year for haemorrhagic stroke in women, and from +0·5% per year for colorectal cancer to -1·8% per year for haemorrhagic stroke in men. For no cause of death did the risk of premature death decline sufficiently fast for most countries to achieve a third reduction by 2030. For liver cancer, colorectal cancer, and the residual group of other cancers in women and men, and lung cancer in women, less than 10% of all countries were on track for a third reduction. Figure 3 shows the average annual rate of change over 2010-16 in the probability of dying between 30 years and 70 years from NCD4 causes of death by country. Stomach cancer was the fastest declining cause in 45 (25·6%) countries in men and 40 (22·7%) countries in women (figure 3), followed by chronic respiratory diseases in men (37 [21·0%] countries) and ischaemic stroke in both men and women (33 [18·8%] countries). The probability of dying from all these causes is declining in 14 (8·0%) countries for men and in 16 (9·1%) countries for women. In 18 (10·2%) other countries for men and 25 (14·2%) for women, the probability of dying is declining for all but one cause. In Papua New Guinea, the probability of dying prematurely for every single cause of death is on the rise in men. In Haiti and Mauritania, the probability is on the rise for Yearly percentage change in cause-specific probability of dying by percentiles of countries Yearly percentage change in cause-specific probability of dying by percentiles of countries The tenth percentile indicates the rate of change that the top 10% of countries (18) are declining faster than, the 50th percentile is the median rate of change, and the 90th percentile shows the rate of change which 10% (18) Annual change (%) Uzbekistan (1) Yemen (4) Malawi ( all causes of death but one for men. In a further 37 (21·0%) countries for men and 26 (14·8%) for women, the probability of death is rising for at least half of the causes of death. Premature mortality from a larger number of NCD4 causes of death is declining for high-income countries in Asia-Pacific compared with other regions. Premature mortality from many of these causes is also declining in east and southeast Asia and central Asia, the Middle East, and North Africa for women, and the high-income western countries and central and eastern Europe for men. The least favourable changes in the probability of death from these causes were seen in sub-Saharan Africa, and for men in south Asia and Oceania. Among highincome countries, the USA did badly, with probability of death from all but three causes of death increasing in both men and women. As stated earlier, women in 17 countries and men in 15 ( Figure 3 continues on next page) this target, we constructed a series of scenarios that each define a specific combination of reductions in the risk of premature death from NCD4 causes of death. To construct the scenarios, two types of decline for each NCD cause of death were considered: fast (or ambitious) and average. The fast decline corresponds to the probability of premature death for a cause of death declining at the same (annual) rate as the tenth best performing percentile of all countries (the countries that fall in the top 10% for each disease are marked with a gold dot in figure 3 ). The average decline corresponds to the probability of premature death for a cause declining at the same (annual) rate as the median of all countries. For both types of decline, in countries where the decline is already faster than the benchmarks, their own rate of decline was used. For causes of death in which median change indicated an increase in the probability of premature death (lung cancer among women and colorectal, liver, and prostate cancers among men; figure 2) , a zero rate of change was applied so that guidance on pathways does not suggest a rise in mortality. For each scenario and each country, we evaluated whether the specific combination of reductions in cause-specific probabilities of death would be sufficient to achieve SDG target 3.4 (appendix pp 8-9). The successful scenarios represent the pathways to SDG target 3.4 available to each country (appendix pp [21] [22] . These scenarios frame the reduction in premature mortality in each cause of death based on the actual experience and achievement of all countries in the world. These choices of benchmarks imply that all countries could do as well as the median country in reducing cause-specific mortality and that a decline, as large as the tenth percentile of best performing countries, although ambitious, is within reach. This approach is comple mentary to modelling the role of specific interventions, 6, 7 which shows the potential of specific actions but might miss out on what is not measured or modelled. Achieving the sort of reductions envisioned by these scenarios requires appropriate financing, infrastructure, and policies. Each scenario represents one combination of fast (or ambitious) and average declines in probability of premature death from the different causes of death. Angola, 43% Average rate sufficient in all scenarios to achieve target Fast rate essential in all scenarios to achieve target ( Figure 5 continues on next page) Whether a scenario is successful in achieving a third reduction in a country depends on two things: firstly, the baseline risk of death in that country in 2015 from each of the NCD4 causes of death, and secondly, the fast and average rates of decline for each of those causes of death in that scenario. If the scenario allocates the fast rate of decline to causes of death with higher baseline risks in that country, and if those fast rates of decline are sufficiently rapid to achieve a third reduction by 2030, then the scenario reduces the risk of premature death to achieve SDG target 3.4. Otherwise, the needed reduction will not be achieved by that scenario. Therefore, the difference between countries with many versus few successful scenarios is that the former have more deaths in causes of death that are declining more rapidly (eg, stroke, stomach cancer, and chronic respiratory diseases; figure 2) than the latter (appendix pp [10] [11] Average rate sufficient in all scenarios to achieve target Fast rate essential in all scenarios to achieve target ( Figure 5 continues on next page) women and 8192 (2¹³) scenarios for men. Figure 4 shows the percentage of scenarios that would achieve SDG target 3.4 for each country and sex. Every country in the world has some options to achieve SDG target 3.4. There is, however, substantial variation in the options available to countries, with the share of scenarios that could achieve SDG target 3.4 ranging from less than 1% for women in eight countries and men in 12 countries to over 50% for women in 29 countries and men in eight countries. In most countries, there are more options to achieve the target for women than for men. Men in most high-income western countries, sub-Saharan Africa, Latin America and the Caribbean, and east and southeast Asia have the potential to achieve SDG target 3.4 with less than 10% of scenarios. There were typically fewer options for women in high-income western countries than in other regions. At the extreme, if every NCD4 cause of death declined at the same rate as the tenth best performing percentile of all countries, the overall probability of dying from NCD4 between 30 years and 70 years of age would decline by 33-51% for women and 34-52% for men in different Average rate sufficient in all scenarios to achieve target Fast rate essential in all scenarios to achieve target For each cause of death in each country the share of successful scenarios (ie, those that meet SDG target 3.4) in which that cause of death is allocated the fast versus the average rate of decline is depicted. If a cause of death accounts for only a small share of NCD4 deaths between people aged 30 years and 70 years, then the cause will not require the fast rate in the successful scenarios and the median rate will suffice. Conversely, if a cause of death accounts for a large share of NCD4 deaths in a country, especially one for which the global median decline is slow, then a high percentage of scenarios must include the fast decline to achieve success. The numbers next to each country show the percentage of all possible disease reduction scenarios that would achieve SDG target 3.4 (values from figure 4) . Countries in pale green are those that are already on track to achieve the target. The cells marked with a gold dot show cause-of-death and country combinations in countries that were in the fastest 10% of declines. The cells marked with a grey-white circle show causes-of-death and country combinations for countries in which a fast decline was necessary for all successful scenarios. SDG=Sustainable Development Goals. NCD4=four non-communicable diseases including cancers, cardiovascular diseases, chronic respiratory diseases, and diabetes. countries (appendix pp [23] [24] [25] . The median decline would be 42% for women and 38% for men. No country can achieve SDG target 3.4 by addressing a single cause of death. Rather, the minimum number of causes requiring a decline at the fast rate in a successful scenario in any country was two for women and three for men, although in most countries even more causes would have to be ambitiously improved at the same time. For example, in half of the countries, successful scenarios require improving the rate of decline in at least five causes of death to that of the tenth best performing percentile of all countries for women, and that of seven causes for men. Figure 5 shows how often each cause had to be on a fast-track in successful scenarios for each country, which measure the degree of necessity of reducing each cause of death at the fast rate to achieve the target. In addition to providing information for individual countries, a few regional or global patterns arise: women in high-income western countries generally require a faster decline in the risk of dying from a greater number of causes of death than in other regions, than do men in the same region. As an extreme example, women in France would need a fast decline in every single cause of death to achieve a third reduction in probability of dying from NCD4 between 30 years and 70 years (appendix pp [10] [11] . This situation arises from the fact that deaths in women aged between 30 and 70 years in high-income countries are spread across many causes (figure 1), all of which would have to be reduced at a fast rate to lower the overall risk of death within the SDG time frame. Fast reductions in ischaemic heart disease deaths are necessary so that men in most countries achieve SDG target 3.4. For men and women in many high-income western countries, and men in central and eastern Europe and east and southeast Asia, fast reductions in lung cancer deaths are also necessary to achieve the target, as are fast reductions in deaths from liver cancer and haemorrhagic stroke for men in east and southeast Asia. Diabetes mortality would have to decline fast in all countries in Oceania, and for men in many countries in Latin America and the Caribbean, and sub-Saharan Africa, whereas reducing breast cancer deaths at a fast rate is necessary for women in many high-income western countries and in Japan. Finally, fast reductions in mortality for the heterogeneous group of other cancers are necessary to meet SDG target 3.4 in many highincome western and Asia-Pacific countries, and for women in central and eastern Europe. Across all countries, the causes of death that must decline at the same rate as the tenth best performing percentile of all countries to achieve the target are seen in figure 6 . For women, these were a diverse group, with slightly more countries requiring a fast decline in deaths from lung cancer, ischaemic heart disease, and the aggregate group of other cancers than for other causes. For men, ischaemic heart disease, which consistently posed a higher risk of death than other causes (figure 1), must decline rapidly in 124 (70·5%) countries to achieve Number of countries in which disease must decline at 10th percentile rate, including those in the top 10% Figure 6 : Number of countries in which a cause of death must be declining with a fast trend to achieve SDG target 3. 4 The numbers exclude countries that are already on track to achieve SDG target 3.4 (shown in pale green in figures 4, 5) but include countries in which the decline is already in the top 10%. SDG=Sustainable Development Goal. SDG target 3.4, followed by a much smaller number of countries for diabetes (which has shared causes and interventions with ischaemic heart disease and other cardiovascular diseases), lung cancer, and the cluster of other cancers. Results by region are summarised (appendix pp 44-46). The indicator for SDG target 3.4 excludes NCDs other than NCD4 and deaths in people younger than 30 years of age, and 70 years and older. In 2015, which is the baseline year for SDGs, there was a total of 39·7 million NCD deaths in the 176 countries in our analysis. An estimated 1·7 million NCD deaths were in people younger than 30 years of age (4% of all 39·7 million NCD deaths; 18% of all 9·6 million deaths in this age group, with the remaining 82% of 9·6 million deaths from injuries and communicable, maternal, perinatal, and nutritional conditions). Of these, about 0·6 million deaths were estimated to be from NCD4 and 1·2 million from all other NCDs. Deaths from NCDs other than NCD4 in people aged between 30 and 70 years were not included in the indicator. These causes of death were responsible for 2·6 million deaths, accounting for 17% of all 15·0 million NCD deaths in those aged between 30 and 70 years. In addition, an estimated 23·0 million NCD deaths in people aged 70 years and older (58% of all NCD deaths) are not included. Of these, an estimated 10·2 million were in people aged 70-79 years, and 12·8 million in people aged 80 years and older. 18·9 million of these deaths were from NCD4 and 4·1 million from other NCDs. The previous NCD Countdown paper 3 showed that the risk of dying from NCDs other than NCD4 and in age groups other than those between 30 and 70 years is higher in low-income and middle-income countries than in high-income countries. Many of these causes of death also share interventions with NCD4. For example, chronic kidney disease, which is not included in NCD4, is affected by some of the same risk factors and interventions as diabetes and cardiovascular diseases, which are included. For these reasons, NCD Countdown 2030 also reports on deaths from all NCDs as well as suicide (as a mortality indicator for mental health) in people less than 80 years of age. 3 In 2015, there were an estimated 0·79 million deaths by suicide in the world. 0·23 million (29%) of these were people aged younger than 30 years, 0·45 million (57%) were between ages 30 years and 70 years, and the remaining 0·12 million (15%) were 70 years and older. Results for all NCDs plus suicide and the broader age group of birth to 80 years of age are shown in the appendix pp 26-42. The probability of dying prematurely from all NCDs and suicide between birth and 80 years of age was highest in sub-Saharan Africa and central Asia for both sexes, and in eastern Europe for men (appendix pp 26-28). Among non-NCD4 causes of death, liver cirrhosis, kidney and other genitourinary diseases, neurological conditions, and mental and substance-use disorders and suicide are all responsible for substantial risk of dying before 80 years of age, especially in low-income and middle-income countries (appendix pp 29-30). The rate of change in the probability of dying before 80 years of age from these causes of death is highly variable across countries, with many countries having had an increase. In particular, the risk of dying from neurological conditions between birth and 80 years of age has increased for more than half of countries (appendix pp 36-37). The pathways analysis of feasible reductions in mortality shows that, if every one of these causes of death declined at the same annual rate as the tenth best performing percentile of all countries, the probability of dying before 80 years of age from all NCDs plus suicide would decline by 31-44% for women and 26-40% for men in different countries (appendix pp 40-42). The median decline would be 36% for women and 30% for men. Leveraging the pathways to achieve SDG target 3.4 The analysis of pathways shows that, based on actual experience in reducing NCD mortality in countries with good performance, every country has one or more pathways to achieve target SDG 3.4 by 2030. Nonetheless, for many countries doing so is an ambitious task and requires tackling several NCDs to the same extent as achieved by the best performing nations. The pathways analysis also revealed that neither globally nor regionally does a specific cause of death emerge as a single solution for achieving SDG target 3.4. Large reductions in the risk of death from ischaemic heart disease are necessary so that many countries can achieve the target for men. For women, various cancers, diabetes, and chronic respiratory diseases must also be tackled. Importantly, successful scenarios require achieving the same reduction as the best performing countries for several causes of death. NCDs have several social, environmental, behavioural, nutritional, and clinical determinants. The diverse disease-specific pathways show that reducing the burden of NCDs to achieve SDG target 3.4 requires a combination of prevention, early detection, and treatment. 5, 8 With cardiovascular diseases, chronic respiratory diseases, diabetes, and some cancers requiring large reductions, essential components of any strategy to achieve SDG target 3.4 include tobacco and alcohol control, detection and treatment of hypertension and diabetes, primary and secondary prevention of cardiovascular diseases in highrisk individuals through multidrug treatment, and lowdose inhaled corticosteroids and bronchodilators for asthma and selected patients with chronic obstructive pulmonary disease. [5] [6] [7] 9, 10 Experiences from high-income countries show that these population-based and primary care interventions, although essential and effective on their own do not lead to large enough reductions to achieve SDG target 3.4. Rather, substantially reducing cardiovascular disease and respiratory disease mortality also requires high-quality care, including treat ment of acute cardiovascular disease, acute exacerbations of asthma and chronic obstructive pulmonary disease, and acute complications of diabetes, at first-level (eg, district), regional, and specialist hospitals. [10] [11] [12] [13] [14] [15] [16] [17] The pathways analysis also showed the importance of reducing deaths from cancers for achieving SDG target 3.4. Tobacco control, and, to a lesser extent, alcohol control, are effective interventions against cancers with benefits emerging within a few years. 6, 7, 9 Vaccinations against human papillomavirus and hepatitis B virus are highly effective cancer-prevention measures for cervical and liver cancers, which cause a large number of deaths, especially in low-income and middle-income coun tries, 5, 9, 18, 19 and should be used in all countries. Although of essential importance, the benefits of immunisation on mortality will materialise decades beyond the current targets. In the interim, leveraging the pathways to SDG target 3.4 requires closing the cancer diagnosis and survival gap between high-income countries and low-income and middleincome countries 20 through screening. This approach will allow earlier diagnosis during precancerous or early stages of disease, followed by treatment of those cancers with effective treatment. 9, 19 An assessment of specific interventions for different NCDs, together with estimates of the costs of these interventions and the opportunities and challenges for their implementation, is detailed in a forthcoming NCD Countdown 2030 analysis. The diverse national pathways show that accelerating progress towards SDG target 3.4 requires two important considerations. First, national NCD strategies based on the combination of local epidemiology and feasibility, and second, an accessible and equitable health system that integrates population-based prevention with the entire continuum of care (appendix p 12)-from primary care to secondary and specialist hospital care with effective and efficient referral pathways and the ability to retain patients in long-term care-17 rather than isolated and vertical programmes. 21 Such an integrated approach is challenging in low-income countries, which continue to face a substantial burden of infectious diseases, epidemic outbreaks (such as Ebola and COVID-19, which influence acute and chronic care for NCDs), and humanitarian crises. Putting in place mechanisms for early diagnosis, appropriate and efficient referral, and long-term care for NCDs would better prepare health systems to deal with other chronic and acute conditions. Creating such a system requires additional financing for NCDs, 22 aligning the NCD agenda with efforts to achieve accessible and equitable national health systems through universal health coverage, 23 and strengthening the capacity for priority setting 24 and implementation of NCD care within the health system. Disease burden and mortality estimates: cause-specific mortality 3 NCD Countdown 2030 collaborators. NCD Countdown 2030: worldwide trends in non-communicable disease mortality and progress towards Sustainable Development Goal target 3.4 Transforming our world: the 2030 agenda for sustainable development Acting on non-communicable diseases in low-and middle-income tropical countries Contribution of six risk factors to achieving the 25×25 non-communicable disease mortality reduction target: a modelling study Regional contributions of six preventable risk factors to achieving the 25 × 25 non-communicable disease mortality reduction target: a modelling study Can noncommunicable diseases be prevented? Lessons from studies of populations and individuals Costs, affordability, and feasibility of an essential package of cancer control interventions in low-income and middle-income countries: key messages from Disease Control Priorities respiratory, and related disorders: key messages from Disease Control Priorities Contributions of risk factors and medical care to cardiovascular mortality trends Medical management and the decline in mortality from coronary heart disease Coronary heart disease epidemiology: from aetiology to public health Estimation of contribution of changes in coronary care to improving survival, event rates, and coronary heart disease mortality across the WHO MONICA Project populations Acute myocardial infarction hospital admissions and deaths in England: a national follow-back and follow-forward record-linkage study Short-term and longterm outcomes in 133,429 emergency patients admitted with angina or myocardial infarction in Scotland High-quality health systems in the Sustainable Development Goals era: time for a revolution Global cancer transitions according to the Human Development Index (2008-2030): a population-based study WHO report on cancer: setting priorities, investing wisely and providing care for all. Geneva: World Health Organization Global surveillance of trends in cancer survival 2000-14 (CONCORD-3): analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries It's time to walk the talk: WHO independent high-level commission on noncommunicable diseases final report. Geneva: World Health Organization A chronology of global assistance funding for NCD Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities In health spending, middle-income countries face a priorities ditch, not a financing ditch-but that still merits aid. Center for Global Development RBe, RBo, KD, LMR, and ME developed and established the NCD Countdown initiative. ME developed the pathways analysis concept. JEB, VK, MG, CDM, and ME developed analytical design with input from other authors. JEB and VK analysed data and presented results with input from other authors. ME, JEB, and VK wrote the first draft of the paper, with input from other authors. ME oversaw the study. The authors alone are responsible for the views expressed in this paper and they do not necessarily represent the views, decisions, or policies of the institutions with which the authors are affiliated. This work was funded by Research England. Editorial note: the Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.