Non-communicable disease policy implementation from 2014 to 2021: a repeated cross-sectional analysis of global policy data for 194 countries.

BACKGROUND: Non-communicable diseases (NCDs) are the world's leading cause of death and disability. Global implementation of WHO-recommended NCD policies has been increasing with time, but in 2019 fewer than half of these policies had been implemented globally. In 2022, WHO released updated data on NCD policy implementation, on the basis of surveys conducted in 2021 during the COVID-19 pandemic. We sought to examine whether the trajectory of global policy implementation changed during this period. METHODS: In this repeated cross-sectional analysis, we used data from the 2015, 2017, 2020, and 2022 WHO progress monitors to calculate NCD policy implementation scores for all 194 WHO member states. We used Welch's ANOVA and Games-Howell post-hoc pairwise testing to examine changes in mean implementation scores for 19 WHO-recommended NCD policies, with assessment at the global, geographical, geopolitical, and country-income levels. We collated sales data on tobacco, alcohol, and junk foods to examine the association between changes in sales and the predicted probability of implementation of policies targeting these products. We also calculated the Corporate Financial Influence Index (CFII) for each country, which was used to assess the association between corporate influence and policy implementation. We used logistic regression to assess the relationship between product sales and the probability of implementing related policies. The relationship between CFII and policy implementation was assessed with Pearson's correlation analysis and random-effects multivariate regression. FINDINGS: Across the 194 countries, in the years preceding publication of each progress monitor, mean total policy implementation score (out of a potential 18·0) was 7·0 (SD 3·5) in 2014, 8·2 (3·5) in 2016, 8·6 (3·6) in 2019, and 8·6 (3·6) in 2021. Only the differences in mean implementation score between 2014 and the other three report years were deemed statistically significant (pairwise p<0·05). Thus the steady improvement in mean global NCD policy implementation stalled in 2021 at 47·8%. However, from 2019 to 2021, we identified shifts in individual policies: global mean implementation scores increased for policies on tobacco, clinical guidelines, salt, and child food marketing, and decreased for policies on alcohol, breastmilk substitute marketing, physical activity mass media campaigns, risk factor surveys, and national NCD plans and targets. Six of the seven policies with the lowest levels of implementation (global mean score <0·4 out of a potential 1·0) in both 2019 and 2021 were related to tobacco, alcohol, and unhealthy food. From 2020 onwards, we identified weak or no associations between sales of tobacco, alcohol, and junk foods and the predicted probability of implementing policies related to each commodity. Country-level CFII was significantly associated with total policy implementation score (Pearson's r -0·49, 95% CI -0·59 to -0·36), and this finding was supported in multivariate modelling for all policies combined and for all commercial policies except alcohol policies. INTERPRETATION: NCD policy implementation has stagnated. Progress in the implementation of some policies is matched by decreased implementation of others, particularly those related to unhealthy commodities. To prevent NCDs and their consequences, and attain the Sustainable Development Goals, the rate of NCD policy adoption must be substantially and urgently increased before the next NCD progress monitor and UN high-level meeting on NCDs in 2024. FUNDING: None.

The Case for Integrating Health Systems to Manage Noncommunicable and Infectious Diseases in Low- and Middle-Income Countries: Lessons Learned From Zambia.

Noncommunicable diseases (NCDs) are the leading cause of death in the world, and 80% of all NCD deaths occur in low- and middle-income countries (LMICs). The COVID-19 pandemic has demonstrated that patients with NCDs are at increased risk of becoming severely ill from the virus. Disproportionate investment in vertical health programs can result in health systems vulnerable to collapse when resources are strained, such as during pandemics. Although NCDs are largely preventable, globally there is underinvestment in efforts to address them. Integrating health systems to collectively address NCDs and infectious diseases through a wide range of services in a comprehensive manner reduces the economic burden of healthcare and strengthens the healthcare system. Health system resiliency is essential for health security. In this article, we provide an economically sound approach to incorporating NCDs into routine healthcare services in LMICs through improved alignment of institutions that support prevention and control of both NCDs and infectious diseases. Examples from Zambia's multisector interventions to develop and support a national NCD action plan can inform and encourage LMIC countries to invest in systems integration to reduce the social and economic burden of NCDs and infectious diseases.

COVID-19 vaccine hesitancy among Nigerians living with non-communicable diseases: a qualitative study.

OBJECTIVES: The discovery and subsequent manufacture of various types of COVID-19 vaccines were considered a breakthrough in the fight against the COVID-19 pandemic. Initially, limited supplies of COVID-19 vaccines warranted vulnerable populations such as people living with chronic non-communicable diseases and the elderly to be prioritised for vaccination. Nevertheless, the uptake of the COVID-19 vaccines among these populations was suboptimal. In this study, we aimed to describe the drivers of COVID-19 vaccine hesitancy among people living with chronic non-communicable diseases in Ibadan, Nigeria. METHOD: We applied qualitative methods to explore the feelings and thoughts of people living with chronic non-communicable diseases towards COVID-19 vaccines, at a tertiary hospital in Ibadan, Nigeria. Data were obtained from 25 people living with chronic conditions through in-depth interviews. We thematically analysed the transcripts inductively and deductively. Dedoose qualitative data management software was used to manage the data. FINDINGS: Emerging subthemes were grouped into two major themes: Hesitancy towards the COVID-19 vaccine related to biological concerns and those related to sociopolitical issues. Hesitancy towards the COVID-19 vaccine associated with biological factors included: (1) concerns over the COVID-19 vaccine worsening the underlying chronic condition; (2) fear of harmful physiological consequences; (3) concerns over insufficient testing of vaccine for safety and (4) perceived vaccine infectiveness. Sociopolitical factors were related to (1) misconceptions of vaccines as a treatment for those with COVID-19; (2) mistrust of manufacturers ('the whites'); (3) mistrust of government and (4) COVID-19 misinformation. CONCLUSION: Public health education on the nature and benefits of the COVID-19 vaccine is urgently needed among people living with chronic non-communicable diseases. These measures could improve COVID-19 vaccine uptake and healthcare usage in general. Paying attention to these factors could have implications for the management of the next global pandemic requiring mass vaccination.

Behavioral and Dietary Habits That Could Influence Both COVID-19 and Non-Communicable Civilization Disease Prevention-What Have We Learned Up to Now?

The massive expansion of the new coronavirus SARS-CoV-2 has urged countries to introduce lockdowns and set restrictive actions worldwide. The focus of the studies was to determine how COVID-19 induces damage to the lungs in order to find an alternative or adjuvant therapy that could lead to preventing COVID-19 or at least ameliorating it. This paper aims to survey the literature and provide new insights into behavioral and dietary habits that could influence the prevention of COVID-19. Maintaining an adequate mental health status, sleep, and taking moderate exercise are often disrupted in the conditions of lockdown and are followed by weakened immunity. Mediterranean and vegetarian diets are superior to other eating patterns in terms of immunity boosting and fighting COVID-19. Our study showed how adequate hydration, green tea intake, and supplementation with vitamins D, C, and E can increase our chances of avoiding the infection and even help us sleep better. Another focus of the research was on determining what level of hygiene really increases one's chances of not contracting SARS-CoV-2, but this seems a little counter-intuitive at first. Since an immunocompromised state is a familiar predisposing factor for all contagious diseases, maintaining healthy behavioral and dietary habits could be a crucial step in boosting immunity and preventing COVID-19.

Counselling of non-communicable diseases' patients for COVID-19 vaccine uptake in Jordan: Evaluating the intervention.

BACKGROUND: People with noncommunicable diseases (NCDs) are at a significantly higher risk of worst outcomes if infected with COVID-19 and thus amongst the main target population for vaccination. Despite prioritizing them for vaccination, the number of vaccinated patients with comorbidities stalled post vaccine introduction. Despite that the government along with partners ran a national awareness campaign to ramp up vaccination coverage, the coverage remained suboptimal. Thus, a one-to-one health counselling initiative was implemented to explore the acceptance of COVID-19 vaccines by the NCDs patients and address the main issues surrounding vaccine hesitancy. This study evaluates the impact of this intervention by analyzing the change in COVID-19 vaccine acceptance. METHODS: In this analytical observational study, a random sample of 57,794 people living with NCDs were approached. Out of them, 12,144 received one-to-one counselling by a group of trained health professionals. The counselled group's vaccine acceptance was assessed on a Likert scale from 1 to 5 pre- and post- counselling. Moreover, a random sample was followed up 2 months after initial counselling to measure their vaccine acceptance and update their vaccination status. RESULTS: 44.5% of total respondents were already registered in the vaccination platform. On a scale from 1 to 5, the overall mean confidence significantly increased by 1.63 from 2.48 pre-counselling to 4.11 post-counselling. Two-months post counselling, a random sample was contacted again and had a mean vaccine confidence of 3.71, which is significantly higher than pre-counselling confidence level despite a significant decrease to post-counselling results. DISCUSSION: Implementing an intervention that targets all key factors impacting health decisions, such as health literacy, risk appraisal and response efficacy, helps reach an adaptive response and increase vaccine confidence. Scholars should be cautious when implementing an intervention since it could lead to maladaptive defensive responses. One-to-one interventions are more effective in population when addressing new interventions and vaccines.

Preventing the Next Pandemic: The Case for Investing in Circulatory Health - A Global Coalition for Circulatory Health Position Paper.

The Coronavirus Disease 2019 (COVID-19) has had a continuous and robust impact on world health. The resulting COVID-19 pandemic has had a devastating physical, mental and fiscal impact on the millions of people living with noncommunicable diseases (NCDs). In addition to older age, people living with CVD, stroke, obesity, diabetes, kidney disease, and hypertension are at a particularly greater risk for severe forms of COVID-19 and its consequences. Meta-analysis indicates that hypertension, diabetes, chronic kidney disease, and thrombotic complications have been observed as both the most prevalent and most dangerous co-morbidities in COVID-19 patients. And despite the nearly incalculable physical, mental, emotional, and economic toll of this pandemic, forthcoming public health figures continue to place cardiovascular disease as the number one cause of death across the globe in the year 2020. The world simply cannot wait for the next pandemic to invest in NCDs. Social determinants of health cannot be addressed only through the healthcare system, but a more holistic multisectoral approach with at its basis the Sustainable Development Goals (SDGs) is needed to truly address social and economic inequalities and build more resilient systems. Yet there is reason for hope: the 2019 UN Political Declaration on UHC provides a strong framework for building more resilient health systems, with explicit calls for investment in NCDs and references to fiscal policies that put such investment firmly within reach. By further cementing the importance of addressing circulatory health in a future Framework Convention on Emergency Preparedness, WHO Member States can take concrete steps towards a pandemic-free future. As the chief representatives of the global circulatory health community and patients, the Global Coalition for Circulatory Health calls for increased support for the healthcare workforce, global vaccine equity, embracing new models of care and digital health solutions, as well as fiscal policies on unhealthy commodities to support these investments.

Linking health and finance ministries to improve taxes on unhealthy products.

The World Health Organization recommends economic measures such as taxes on tobacco, alcohol and unhealthy foods and beverages as part of a comprehensive strategy for prevention of noncommunicable diseases. However, progress in adopting these so-called health taxes has been hampered, in part, by different approaches and perceptions of key issues in different sectors of government. Health promotion is the responsibility of health policy-makers, while taxation is the mandate of finance ministries. Thus, strengthening cooperation between health and finance policy-makers is central to the successful adoption and implementation of effective health taxes. In this paper we identify the shared concerns of finance and health policy-makers about health taxes with the aim of enabling more effective cross-sector cooperation towards both additional financing for health systems and changes in unhealthy behaviours. For example, new approaches to supporting health taxation include the growing priority for health-system financing due to the growing burden of noncommunicable diseases, and the need to address the health and economic damage due to the coronavirus disease 2019 pandemic. As a result, high-level efforts to achieve progress on health taxes are gaining momentum and represent important progress towards using the combined expertise of health and finance policy-makers.

L'Organisation mondiale de la Santé recommande l'adoption de mesures économiques telles que des taxes sur le tabac, l'alcool ainsi que les boissons et aliments nocifs pour la santé dans le cadre d'une vaste stratégie de prévention des maladies non transmissibles. Cependant, les progrès en la matière ont rencontré des obstacles, notamment en raison de la différence d'approche et de perception des principaux enjeux à divers niveaux du gouvernement. La promotion de la santé relève de la politique sanitaire, tandis que la taxation est la mission du ministère des Finances. Accentuer la coopération entre les responsables de la santé et des finances est donc indispensable à la réussite de l'instauration et de la mise en œuvre de taxes sanitaires efficaces. Dans le présent document, nous identifions les préoccupations partagées tant par les responsables de la santé que par ceux des finances concernant les taxes sanitaires, dans le but d'intensifier la collaboration entre les secteurs. Objectif: débloquer des fonds supplémentaires pour les systèmes de santé et favoriser l'abandon des comportements nuisibles à la santé. Parmi les nouvelles approches de soutien aux taxes sanitaires, citons par exemple une plus grande priorité accordée au financement du système de santé afin de réduire la charge croissante que font peser les maladies non transmissibles, et la nécessité de réparer les dégâts économiques et sanitaires causés par la pandémie de maladie à coronavirus 2019. Ainsi, les efforts visant à développer les taxes sanitaires gagnent du terrain et représentent une avancée considérable vers une valorisation de l'expertise conjointe entre ministère de la Santé et ministère des Finances.

La Organización Mundial de la Salud recomienda la adopción de medidas económicas como los impuestos sobre el tabaco, el alcohol y los alimentos y bebidas poco saludables como parte de una estrategia global de prevención de las enfermedades no transmisibles. Sin embargo, los avances en la adopción de estos llamados impuestos saludables se han retrasado, en parte, por los diferentes enfoques y percepciones de las cuestiones clave en los distintos sectores del gobierno. La promoción de la salud es competencia de los responsables de formular las políticas sanitarias, mientras que la fiscalidad es el mandato de los ministerios de Hacienda. Por lo tanto, el fortalecimiento de la cooperación entre los responsables de formular las políticas sanitarias y financieras es fundamental para el éxito de la adopción y aplicación de sistemas fiscales sanitarios eficaces. En este documento, se identifican las preocupaciones que comparten los responsables de formular las políticas financieras y sanitarias en relación con los impuestos saludables, con el fin de permitir una cooperación intersectorial más eficaz, tanto en lo que respecta a la financiación adicional de los sistemas sanitarios como a la modificación de los comportamientos poco saludables. Por ejemplo, entre los enfoques nuevos para apoyar la fiscalidad sanitaria se encuentran la creciente prioridad de la financiación de los sistemas sanitarios debido a una mayor carga de enfermedades no transmisibles, y la necesidad de solucionar los daños sanitarios y económicos debidos a la pandemia de la enfermedad por coronavirus de 2019. En consecuencia, los esfuerzos de alto nivel para lograr avances en materia de impuestos saludables están cobrando impulso y representan un avance importante hacia el uso de la experiencia combinada de los responsables de formular las políticas sanitarias y financieras.

A rapid assessment of the impact of coronavirus disease (COVID- 19) pandemic on health care & service delivery for noncommunicable diseases in India.

BACKGROUND AND AIM: The coronavirus disease (COVID-19) pandemic had disrupted the availability, access and utilisation of routine health care services. The present study aimed to assess the impact of COVID-19 pandemic restrictions on India's Non communicable Disease (NCD) health care service delivery. METHODS: The study included existing hospitals in disease registry network of the Indian Council of Medical Research-National Centre for Disease Informatics and Research (ICMR-NCDIR), Bengaluru. The study participants comprised site investigators who were clinicians from many specialities, including general medicine, surgery, cancer, neurology, cardiology, and endocrinology. A standardised questionnaire was prepared to collect data on NCD health care services at the respective hospitals over three months from March to May 2020. RESULTS: Out of 153 hospitals approached for the study, 106 (70%) agreed to participate. Of these, 16 hospitals fully converted for COVID-19 care were excluded from the study. Thus, data from 90 hospitals were included in the final analysis. There had been a total disruption of NCD-related healthcare services during the three months in 44% of the hospitals. In April 2020, the outpatient attendance for over one-third of the hospitals was reduced by more than 75%. Admissions for planned surgeries for cancer treatment were reduced by more than 75% for about 40% of the hospitals. Preventive activities and population-based screening for diabetes, hypertension and cancer appear to have been adversely affected, with about one-third of the hospitals reporting total disruption in April and May 2020. As many as 60% of the institutions reported adequate availability of doctors. Over 91% of the institutions had preparedness/action plans to ensure the continuity of NCD services. CONCLUSION: The study shows that despite adequate human and material resources, NCD outpatient services, elective surgeries and population-based screening were severely affected. Most institutions were prepared to overcome the pandemic-imposed disruption and ensure a continuum of care for NCDs'.

Implementation research on noncommunicable disease prevention and control interventions in low- and middle-income countries: A systematic review.

BACKGROUND: While the evidence for the clinical effectiveness of most noncommunicable disease (NCD) prevention and treatment interventions is well established, care delivery models and means of scaling these up in a variety of resource-constrained health systems are not. The objective of this review was to synthesize evidence on the current state of implementation research on priority NCD prevention and control interventions provided by health systems in low- and middle-income countries (LMICs). METHODS AND FINDINGS: On January 20, 2021, we searched MEDLINE and EMBASE databases from 1990 through 2020 to identify implementation research studies that focused on the World Health Organization (WHO) priority NCD prevention and control interventions targeting cardiovascular disease, cancer, diabetes, and chronic respiratory disease and provided within health systems in LMICs. Any empirical and peer-reviewed studies that focused on these interventions and reported implementation outcomes were eligible for inclusion. Given the focus on this review and the heterogeneity in aims and methodologies of included studies, risk of bias assessment to understand how effect size may have been compromised by bias is not applicable. We instead commented on the distribution of research designs and discussed about stronger/weaker designs. We synthesized extracted data using descriptive statistics and following the review protocol registered in PROSPERO (CRD42021252969). Of 9,683 potential studies and 7,419 unique records screened for inclusion, 222 eligible studies evaluated 265 priority NCD prevention and control interventions implemented in 62 countries (6% in low-income countries and 90% in middle-income countries). The number of studies published has been increasing over time. Nearly 40% of all the studies were on cervical cancer. With regards to intervention type, screening accounted for 49%, treatment for 39%, while prevention for 12% (with 80% of the latter focusing on prevention of the NCD behavior risk factors). Feasibility (38%) was the most studied implementation outcome followed by adoption (23%); few studies addressed sustainability. The implementation strategies were not specified well enough. Most studies used quantitative methods (86%). The weakest study design, preexperimental, and the strongest study design, experimental, were respectively employed in 25% and 24% of included studies. Approximately 72% of studies reported funding, with international funding being the predominant source. The majority of studies were proof of concept or pilot (88%) and targeted the micro level of health system (79%). Less than 5% of studies report using implementation research framework. CONCLUSIONS: Despite growth in implementation research on NCDs in LMICs, we found major gaps in the science. Future studies should prioritize implementation at scale, target higher levels health systems (meso and macro levels), and test sustainability of NCD programs. They should employ designs with stronger internal validity, be more conceptually driven, and use mixed methods to understand mechanisms. To maximize impact of the research under limited resources, adding implementation science outcomes to effectiveness research and regional collaborations are promising.

Strengthening the primary care workforce to deliver high-quality care for non-communicable diseases in refugee settings: lessons learnt from a UNHCR partnership.

Non-communicable disease (NCD) prevention and care in humanitarian contexts has been a long-neglected issue. Healthcare systems in humanitarian settings have focused heavily on communicable diseases and immediate life-saving health needs. NCDs are a significant cause of morbidity and mortality in refugee settings, however, in many situations NCD care is not well integrated into primary healthcare services. Increased risk of poorer outcomes from COVID-19 for people living with NCDs has heightened the urgency of responding to NCDs and shone a spotlight on their relative neglect in these settings. Partnering with the United Nations Refugee Agency (UNHCR) since 2014, Primary Care International has provided clinical guidance and Training of Trainer (ToT) courses on NCDs to 649 health professionals working in primary care in refugee settings in 13 countries. Approximately 2300 healthcare workers (HCW) have been reached through cascade trainings over the last 6 years. Our experience has shown that, despite fragile health services, high staff turnover and competing clinical priorities, it is possible to improve NCD knowledge, skills and practice. ToT programmes are a feasible and practical format to deliver NCD training to mixed groups of HCW (doctors, nurses, technical officers, pharmacy technicians and community health workers). Clinical guidance must be adapted to local settings while co-creating an enabling environment for health workers is essential to deliver accessible, high-quality continuity of care for NCDs. On-going support for non-clinical systems change is equally critical for sustained impact. A shared responsibility for cascade training-and commitment from local health partners-is necessary to raise NCD awareness, influence local and national policy and to meet the UNHCR's objective of facilitating access to integrated prevention and control of NCDs.

COVID's Impact on Non-communicable Diseases: What We Do Not Know May Hurt Us.

PURPOSE OF REVIEW: In this review, we outline the impacts of the COVID-19 pandemic on non-communicable diseases around the world. RECENT FINDINGS: The mechanisms of COVID-19's impact on non-communicable diseases are both direct and indirect. The direct mechanisms include direct vascular and myocardial injury as well as pancreatic injury increasing incidence of new-onset diabetes. Indirect effects of the pandemic on non-communicable disease include delayed presentation for acute illness including STEMI and the impact of social distancing and quarantine policies on socialization, mental health, physical activity, and the downstream health impacts of inactivity and deconditioning. International focus has been on disease variants, infection control and management, healthcare system, and resource utilization and infection incidence. However, the impact of this pandemic on non-communicable diseases has been largely overlooked but will manifest itself in the coming years to decades.

The need for vaccination in adults with chronic (noncommunicable) diseases in India - lessons from around the world.

Worldwide, chronic diseases (noncommunicable diseases [NCDs]) cause 41 million (71%) deaths annually. They are the leading cause of mortality in India, contributing to 60% of total deaths each year. Individuals with these diseases are more susceptible to vaccine-preventable diseases (VPDs) and have an increased risk of associated disease severity and complications. This poses a substantial burden on healthcare systems and economies, exemplified by the COVID-19 pandemic. Vaccines are an effective strategy to combat these challenges; however, utilization rates are inadequate. With India running one of the world's largest COVID-19 vaccination programs, this presents an opportunity to improve vaccination coverage for all VPDs. Here we discuss the burden of VPDs in those with NCDs, the benefit of vaccinations, current challenges and possible strategies that may facilitate implementation and accessibility of vaccination programs. Effective vaccination will have a significant impact on the disease burden of both VPDs and NCDs and beyond.

What is already known on this topic?Annually, chronic or noncommunicable diseases (NCDs) cause >40 million deaths worldwide and 60% of all deaths in IndiaAdults with these diseases are more susceptible to vaccine-preventable diseases (VPDs); however, vaccine utilization is inadequate in this populationWhat is added by this report?We highlight the benefits of vaccination in adults with NCDs that extend beyond disease preventionWe discuss key challenges in implementing adult vaccination programs and provide practical solutionsWhat are the implications for public health practice?Raising awareness about the benefits of vaccinations, particularly for those with NCDs, and providing national guidelines with recommendations from medical societies, will increase vaccine acceptanceAdequate vaccine acceptance will reduce the VPD burden in this vulnerable population.

NCD Countdown 2030: efficient pathways and strategic investments to accelerate progress towards the Sustainable Development Goal target 3.4 in low-income and middle-income countries.

Most countries have made little progress in achieving the Sustainable Development Goal (SDG) target 3.4, which calls for a reduction in premature mortality from non-communicable diseases (NCDs) by a third from 2015 to 2030. In this Health Policy paper, we synthesise the evidence related to interventions that can reduce premature mortality from the major NCDs over the next decade and that are feasible to implement in countries at all levels of income. Our recommendations are intended as generic guidance to help 123 low-income and middle-income countries meet SDG target 3.4; country-level applications require additional analyses and consideration of the local implementation and utilisation context. Protecting current investments and scaling up these interventions is especially crucial in the context of COVID-19-related health system disruptions. We show how cost-effectiveness data and other information can be used to define locally tailored packages of interventions to accelerate rates of decline in NCD mortality. Under realistic implementation constraints, most countries could achieve (or almost achieve) the NCD target using a combination of these interventions; the greatest gains would be for cardiovascular disease mortality. Implementing the most efficient package of interventions in each world region would require, on average, an additional US$18 billion annually over 2023-30; this investment could avert 39 million deaths and generate an average net economic benefit of $2·7 trillion, or $390 per capita. Although specific clinical intervention pathways would vary across countries and regions, policies to reduce behavioural risks, such as tobacco smoking, harmful use of alcohol, and excess sodium intake, would be relevant in nearly every country, accounting for nearly two-thirds of the health gains of any locally tailored NCD package. By 2030, ministries of health would need to contribute about 20% of their budgets to high-priority NCD interventions. Our report concludes with a discussion of financing and health system implementation considerations and reflections on the NCD agenda beyond the SDG target 3.4 and beyond the SDG period.