80 under 40 by 2020: an equity agenda for NCDs and injuries.

In May, 2013, the World Health Assembly approved a global monitoring and evaluation framework for prevention and control of non-communicable diseases (NCDs). This framework calls for a 25% reduction in deaths from cardiovascular diseases, chronic respiratory diseases, cancer, and diabetes in individuals aged 30–70 years by 2025, or “25 × 25”. Although we applaud this eff ort, we do not feel that it adequately addresses the specifi c health and economic burdens aff ecting lowincome countries, nor those of poor people in middleincome countries. We propose a complementary agenda to reduce premature mortality from all NCDs and injuries (including neuropsychiatric disorders) by 80% in individuals younger than 40 years by the year 2020, or “80 × 40 × 20”. This ambitious target was announced in July, 2013, at the inaugural meeting of the NCD Synergies Network in Kigali, Rwanda, hosted by the Rwandan Ministry of Health and attended by representatives from 18 countries, including policy makers from 13 African health ministries. The Global Burden of Disease Study 2010 showed that two-thirds of life-years lost and disability-adjusted lifeyears (DALYs) due to NCDs and injuries in sub-Saharan Africa were in individuals younger than 40 years. NCDs causing the unacceptable deaths of children and young adults in this population were generally not driven by classic lifestyle risk factors. Disorders included rheumatic and congenital heart diseases, post-infectious renal failure, malignancies, sickle-cell anaemia, type 1 diabetes, asthma, appendicitis, suicide, epilepsy, and road traffi c or workplace injuries. Collectively, these disorders accounted for 36% of the deaths, 33% of years of life lost, and 44% of DALYs in those younger than 40 years in developing countries. Indeed, compared with high-income populations in the Global Burden of Disease Study, the poorest billion people suff ered about 800 000 excess deaths in 2010 from NCDs and injuries in those younger than 40 years, with about half of these premature deaths due to NCDs alone. This represents a problem of comparable magnitude to other global health priorities. To meet the 80 × 40 × 20 target will require additional strategies complementing those identifi ed in the global framework. However, progress towards the global 25 × 25 goal will be quicker if developing countries simultaneously focus on the 80 × 40 × 20 target, which refl ects the epidemiology of these countries and is synergistic with the Millennium Development Goals. Rwanda has adopted this target and has made progress towards it through its integrated health-system strengthening eff orts. Data from the Global Burden of Disease Study 2010 suggest that, from 2000–10, Rwanda achieved a 49% reduction in NCD and injury-related mortality in individuals younger than 40 years (fi gure). These gains seem to have occurred in the context of a 54% decline in all-cause mortality within this age group, and include all NCD subgroups (ranging from 21% for cancers, to 70% for chronic respiratory diseases). In this timeframe, Rwanda’s average annual health expenditure was less than US$27 per head. We believe that 80 × 40 × 20 can be achieved through shifts from prioritisation of specifi c diseases to building of integrated health-service delivery platforms at com munity, health-centre, district hospital, and referral-centre levels. Equitable access to these services, including vaccin ations, diagnostics, medical and surgical care, and palliation, should be assured through universal health coverage. In addition, multisectoral action will be needed to mitigate indoor air pollution, and improve household, workplace, and road safety as part of a global movement for eradication of extreme poverty. Many countries have already made substantial investments in health systems as part of their response to the HIV epidemic. We anticipate that high-quality interven tions to prevent premature deaths from NCDs and injuries could be implemented even more quickly through leveraging of these existing investments.