TRANSITIONING TO GOOD HEALTH AND WELL-BEINGANTOINE FLAHAULTTransitioning toGOOD HEALTH AND WELL-BEINGAntoine Flahault (Ed.)Transitioning to Good Health and Well-BeingTransitioning to Sustainability Series: Volume 3Series Editor: Manfred Max Bergman Volumes in the series: Volume 1: Transitioning to No PovertyISBN 978-3-03897-860-2 (Hbk); ISBN 978-3-03897-861-9 (PDF)Volume 2: Transitioning to Zero HungerISBN 978-3-03897-862-6 (Hbk); ISBN 978-3-03897-863-3 (PDF)Volume 3: Transitioning to Good Health and Well-BeingISBN 978-3-03897-864-0 (Hbk); ISBN 978-3-03897-865-7 (PDF) Volume 4: Transitioning to Quality EducationISBN 978-3-03897-892-3 (Hbk); ISBN 978-3-03897-893-0 (PDF)Volume 5: Transitioning to Gender EqualityISBN 978-3-03897-866-4 (Hbk); ISBN 978-3-03897-867-1 (PDF)Volume 6: Transitioning to Clean Water and SanitationISBN 978-3-03897-774-2 (Hbk);ISBN 978-3-03897-775-9 (PDF)Volume 7: Transitioning to Affordable and Clean EnergyISBN 978-3-03897-776-6 (Hbk); ISBN 978-3-03897-777-3 (PDF)Volume 8: Transitioning to Decent Work and Economic GrowthISBN 978-3-03897-778-0 (Hbk); ISBN 978-3-03897-779-7 (PDF)Volume 9: Transitioning to Sustainable Industry, Innovation and InfrastructureISBN 978-3-03897-868-8 (Hbk); ISBN 978-3-03897-869-5 (PDF)Volume 10: Transitioning to Reduced InequalitiesISBN 978-3-03921-160-9 (Hbk); ISBN 978-3-03921-161-6 (PDF)Volume 11: Transitioning to Sustainable Cities and CommunitiesISBN 978-3-03897-870-1 (Hbk); ISBN 978-3-03897-871-8 (PDF)Volume 12: Transitioning to Responsible Consumption and ProductionISBN 978-3-03897-872-5 (Hbk); ISBN 978-3-03897-873-2 (PDF)Volume 13: Transitioning to Climate ActionISBN 978-3-03897-874-9 (Hbk); ISBN 978-3-03897-875-6 (PDF)Volume 14: Transitioning to Sustainable Life below WaterISBN 978-3-03897-876-3 (Hbk); ISBN 978-3-03897-877-0 (PDF)Volume 15: Transitioning to Sustainable Life on LandISBN 978-3-03897-878-7 (Hbk); ISBN 978-3-03897-879-4 (PDF)Volume 16: Transitioning to Peace, Justice and Strong InstitutionsISBN 978-3-03897-880-0 (Hbk); ISBN 978-3-03897-881-7 (PDF)Volume 17: Transitioning to Strong Partnerships for the Sustainable Development GoalsISBN 978-3-03897-882-4 (Hbk); ISBN 978-3-03897-883-1 (PDF)Antoine Flahault (Ed.) MDPI • Basel • Beijing • Wuhan • Barcelona • Belgrade • Manchester • Tianjin • Tokyo • ClujTransitioning to Good Health and Well-BeingTransitioning to Sustainability SeriesEDITORSAntoine FlahaultInstitute of Global Health,University of Geneva,SwitzerlandFor citation purposes, cite each article independently as indicated below:Author 1, and Author 2. Year. Chapter Title. In Transitioning to Good Health and Well-Being. Edited by Antoine Flahault. Transitioning to Sustainability Series 3. Basel: MDPI, Page Range.EDITORIAL OFFICEMDPISt. Alban-Anlage 664052 Basel, SwitzerlandISBN 978-3-03897-864-0 (Hbk) ISBN 978-3-03897-865-7 (PDF) ISSN: 2624-9324 (Print)ISSN: 2624-9332 (Online)doi:10.3390/books978-3-03897-865-7© 2022 by the authors. Chapters in this volume are Open Access and distributed under the Creative Commons Attribution (CC BY 4.0) license, which allows users to download, copy and build upon published articles, as long as the author and publisher are properly credited, which ensures maximum dissemination and a wider impact of our publications.The book taken as a whole is © 2022 MDPI under the terms and conditions of the Creative Commons license CC BY-NC-ND. Contentsvii ixxi 1 12 313 554 89 5 1116 1337 155About the Editor Contributors Abstracts Global Health Determinants and Limits to the Sustainability of Sustainable Development Goal 3 EDUARDO MISSONITransitioning to Good Health and Well-Being: The Essential Role of BreastfeedingCOLIN BINNS, MI KYUNG LEE AND JANE SCOTTTaxation of Tobacco, Alcohol and Sugar-Sweetened Beverages for Achieving the Sustainable Development Goals VIOLETA VULOVIC AND FRANK J. CHALOUPKATransforming Regional Agrifood Productions to Challenge NCDs—From the DiMeSa Study to the PASSI Project and Beyond GIUSEPPE CARRUBAImpact of Public Health and Sustainability of Global Health Action for Achieving SDG 3 FLORIAN FISCHER AND FRANZISKA CAROWOn the Relationship between Health Sectors’ Digitalization and Sustainable Health Goals: A Cyber Security Perspective STEFAN SÜTTERLIN, BENJAMIN J. KNOX, KAIE MAENNEL, MATTHEW CANHAM AND RICARDO G. LUGOSustainable Work Ability during Midlife and Old Age Functional Health and MortalitySUBAS NEUPANE AND CLAS-HÅKAN NYGÅRDviiAbout the Editor Antoine Flahault MD, PhD in biomathematics. He was appointed as full professor of public health in 2002. He was the founding director of the French School of Public Health (EHESP, Rennes, 2007-2012), co-director of Centre Virchow-Villermé for Public Health Paris-Berlin (Université Descartes, Sorbonne Paris Cité), co-director of the European Academic Global Health Alliance (EAGHA),and president of the Agency for Public Health Education Accreditation (APHEA). He conducted research in mathematical modelling of communicable diseases, chaired the WHO collaborative centre for electronic disease surveillance, and coordinated research on Chikungunya in Indian Ocean (Inserm Prize, 2006; was scientific curator of a large exhibition Epidemik, la Cité des Sciences et de l’Industrie (Paris, Rio and Sao Paulo)). In January 2014, he was appointed as professor of public health at School of Medicine, University of Geneva where he is the founding director of the Institute of Global Health. He was elected corresponding member at Académie Nationale de Médecine (Paris). In January 2014, he had more than 235 scientific publication referenced in Medline.ixBENJAMIN J. KNOXAssociate Professor, Researcher Center for Information and Cyber Security, Norwegian University of Science and Technology, Norway. CLAS-HÅKAN NYGÅRDProfessor, Unit of Health Sciences Faculty of Social Sciences, Tampere University, Finland.COLIN BINNSEmeritus Professor, School of Public Health, Curtin University, Australia.EDUARDO MISSONIProfessor, Department of Policy Analysis and Public Management, Bocconi University, Italy.FLORIAN FISCHERDr., Institute of Public Health, Charité – Universitätsmedizin Berlin, Germany. Institute of Gerontological Health Services and Nursing Research, Ravensburg-Weingarten University of Applied Sciences, Germany.FRANK J. CHALOUPKAProfessor, Institute for Health Research and Policy, University of Illinois at Chicago, USA.FRANZISKA CAROWDr., School of Public Health, Bielefeld University, Germany.GIUSEPPE CARRUBADr., Division of Research and Internationalization (SIRS) ARNAS-Civico, Italy.JANE SCOTTProfessor, School of Public Health, Curtin University, Australia.KAIE MAENNELDr., Researcher Centre for Digital Forensics and Cyber Security, Tallinn University of Technology, Estonia.MATTHEW CANHAMResearch Assistant Professor, Institute for Simulation & Training, University of Central Florida, USA. MI KYUNG LEESenior Lecturer, College of Science, Health, Engineering and Education, Murdoch University, Australia.RICARDO G. LUGOAssociate Professor, Institute of Psychology Inland, Norway University of Applied Sciences, Norway.STEFAN SÜTTERLINProfessor, Faculty of Health and Welfare, Østfold University College, Norway.SUBAS NEUPANEAdjunct Professor, Unit of Health Sciences Faculty of Social Sciences, Tampere University, Finland.VIOLETA VULOVICDr., Institute for Health Research and Policy, University of Illinois at Chicago, USA.ContributorsxiAbstractsGlobal Health Determinants and Limits to the Sustainability of Sustainable Development Goal 3by Eduardo Missoni The Agenda 2030, signed by the Heads of State and Government in 2015, set out 17 Sustainable Development Goals (SDGs) and, for each of them, a number of targets to be reached within the next 15 years, with a total of 169 targets. SDG 3, “ensuring a healthy life and promoting well-being for all at all ages”, provides, among others, Goal 3.8 “achieving universal health coverage, including protection of financial risks, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”. Agenda 2030, unlike the global agenda for the previous fifteen years, which focused on the so-called Millennium Development Goals (MDGs), mainly concerning the poorest countries, involves and commits all governments to the adoption of “indivisible” and universal goals that will help to end poverty by 2030 “once and for all”, and also brings the issue of development back to a global dimension. The~new agenda is not without contradictions. Among other things, it proposes, among its economic objectives, “sustainable, inclusive and sustained growth”, an oxymoron that was pointed out at the beginning of the 1970s, when the Club of Rome showed the “limits of growth” in a finite ecosystem. Thus, the~challenge of sustainability is global and involves all national health systems. Using Universal Health Coverage, SDG 3’s target, which seems to attract most of the attention, as the main focus, the~paper argues that SDG 3’s feasibility and sustainability is highly dependent on transnational determinants which, if left unregulated by appropriate global governance processes, may jeopardize its attainment. Global determinants (international macroeconomic policies, migration, climate change, market forces, technological innovation, etc.) affecting health system functions (stewardship, resources generation, financing and the provision of services) are identified, and their impact analyzed. The~analysis provides suggestions for the identification of an urgent paradigmatic shift to ensure the effective sustainability of SDG 3 in general, and of universal health coverage (UHC) in particular.xiiTransitioning to Good Health and Well-Being: The Essential Role of Breastfeedingby Colin Binns, Mi Kyung Lee and Jane Scott The world is facing unprecedented public health challenges, including changes, due to climate change, that will affect every continent, and limitations on global food and water supplies together with an increasing epidemic of non-communicable disease. The United Nations Sustainable Development Goal 3, “good health and well-being”, includes targets for child mortality, maternal mortality and reducing chronic disease. Breastfeeding is one of the most cost-effective public health interventions available for countries at all levels of development. In the first year of life, appropriate infant nutrition (exclusive breastfeeding to around six months) reduces infant mortality and hospital admissions in infancy by 50% or more. Breastfeeding followed by the introduction of appropriate complementary foods at around six months establishes a healthy microbiome, has a long-term association with reduced rates of childhood illnesses, hospitalizations, obesity and later chronic disease, while improving cognitive development. It is consistent with the historical cultural practices of all societies. While the development of infant formula has been of benefit to some infants, its inappropriate promotion has resulted in a decline of breastfeeding in recent decades, and, as a result, recent health gains in many countries have not been as great as they could have been. Formula use increases health care costs through increased illnesses and hospital admissions. The specific target for non-communicable disease in SDG3 is to reduce premature mortality from chronic disease by one third by 2030. The Global Burden of Disease project has confirmed that the majority of risk for these targets can be attributed to nutrition related targets, and it is estimated that annually 15 million people between the ages of 30 and 69 years die from a non-communicable disease (NCD), the majority from cardiovascular causes. Healthy life course nutrition, beginning in the first 1000 days of life, is a major public health priority in answering this challenge. Breastfeeding, exclusively for about six months, and appropriate complementary feeding, establishes a healthy developmental trajectory. Children are the population segment most susceptible to the effects of climate change, bearing an estimated 80% of the increased burden of disease associated with climate change. The health benefits of breastfeeding will provide some protection against the health effects of climate change, including projected increases in some infectious diseases. Increased breastfeeding will avoid the high environmental costs associated with the production of infant formula, including the use of large quantities of potable water and energy. In contrast, breastfeeding, xiiias well as being the best infant feeding intervention, has a very low environmental impact. An important part of the sustainable development agenda should be to promote breastfeeding and its benefits and to reverse the inappropriate promotion of infant formula.Taxation of Tobacco, Alcohol and Sugar-Sweetened Beverages for Achieving Sustainable Development Goalsby Violeta Vulovic and Frank J. Chaloupka Premature death and disability rates from non-communicable diseases (NCDs) have been rapidly increasing with potentially enormous implications on global economy. Three major risks factors for NCDs are tobacco use, harmful alcohol consumption, and poor diet. National governments can create incentives for behavioral changes in the consumption of these products through fiscal policies, such as price increase through taxation. A substantial body of empirical evidence suggests that a significant increase in prices of tobacco and alcohol products through higher taxes can discourage consumption and reduce their negative impact on the individual’s health and the economy. Emerging increasing evidence on the impact of consumption of sugar-sweetened beverages (SSBs) suggests the same. Consumption of tobacco, alcohol and SSBs can undermine development and attempts at meeting the Sustainable Development Goals (SDGs), including health and well-being, hunger and poverty alleviation, quality education, economic growth, and reduced inequality. The empirical evidence shows a strong causal effect of consumption of tobacco, alcohol, and SSBs on NCDs. The attributable estimated economic costs can be very high, and significantly higher than the tax collection on consumption of these goods. Moreover, consumption of tobacco, alcohol, and SSBs can crowd-out spending on food and nutrition and increase hunger. In addition, the attributed NCDs can lead to lost productivity and earnings, as well as high out-of-pocket medical expenses for their treatment, putting an individual and their families into a vicious circle of poverty. At the same time, children may be forced to drop out of school to take care of ill family members or to work to make up for lost earnings, denying them educational opportunities and having an intergenerational impact on their and their country’s economic development and growth. This paper reviews the empirical evidence on the impact of consumption of tobacco, alcohol, and SSBs on SDGs to make a strong case to support a significant tax and price increase to help achieving a country’s development goals.xivTransforming Regional Agrifood Productions to Challenge NCDs—From the DiMeSa Study to the PASSI Project and Beyondby Giuseppe Carruba Today, the crisis of the agrifood sector across several geographical European regions, including our own, combined with social, economic and health inequalities at regional, national and community levels, is characterized by extremely critical aspects, mainly residing in the limited innovation potential of companies and small/medium enterprises (SMEs), the lack of integration with public–private research institutions, the insufficient systematization and organization of the existing resources in an extended territorial networking. This results in increasing difficulties of SMEs to exist in both domestic and foreign markets with characteristics of quality and competitiveness. On the other hand, several epidemiological studies clearly indicate that Western countries, including Italy, are witnessing a dramatic phenomenon consisting of an increasingly large prevalence of chronic noncommunicable diseases (NCDs), including cardio-, cerebrovascular and respiratory diseases, diabetes, obesity and cancer, whose causes are primarily related to (removable) lifestyle risk factors, notably diet. Based on this two-sided consideration, promoting both the sustainable consumption and production of traditional food products in regional, domestic and international markets—through a series of activities aimed at increasing their health and/or nutraceutical potential, to clinically validate their effects on both health and chronic disease(s), and to enable the rapid technological transfer and development of either processes or products—would represent a systemic strategy of high impact in the short, medium and long term for important expected outcomes from an economic, technological and healthcare standpoint. Lessons learned from the Dieta Mediterranea e Salute (DiMeSa) study and its recent advancement, the PASSI project, with both published and unpublished results, are presented and discussed here.Impact of Public Health and Sustainability of Global Health Action for Achieving SDG 3by Florian Fischer and Franziska Carow Global health is an area for research and practice that places a priority in improving health and achieving health equity for all people worldwide. Therefore, it corresponds with the aims of the Sustainable Development Goals (SDGs) for providing universal health coverage and leaving no one behind (SDG 3). Public xvhealth is understood as global health on a regional or local level. Whereas “old” public health focused mainly on the prevention of infectious diseases and the healthcare for specific subgroups at risk, “new” public health takes a holistic and interdisciplinary perspective on aspects related to health and well-being. Inter alia, public health genuinely deals with the reduction of health inequalities and risk factors---not only by prevention on a behavioural level, but also on a structural level, such as environment and society. Thus, we understand health as part of each of the 17 SDGs. In a world characterised by globalisation as well as epidemiologic and demographic transitions, the impact and sustainability of global health action needs to be taken into account to improve the world population’s well-being. Therefore, this contribution highlights present and future challenges for global health. Furthermore, it provides overarching suggestions and policy advices for improvements to strengthen a global response on today’s challenges and to gain the targets set within the SDGs, by pointing out that almost all of the 17 SDGs are relevant for health-related issues.On the Relationship between Health Sectors’ Digitalization and Sustainable Health Goals: A Cyber Security Perspectiveby Stefan Sütterlin, Benjamin J. Knox, Kaie Maennel, Matthew Canham andRicardo G. Lugo The healthcare system’s efficiency and effectiveness depend on policies and procedures, such as the rapid and goal-directed exchange of health-related information between its different actors. In recent years, more national healthcare systems approached sustainable health benefits for their populations by digitalization. Despite numerous advantages such as the improved availability of medical services, their improved quality and cost-effectiveness, new vulnerabilities threatened the trust in the healthcare system. Healthcare institutions are a primary target for cyber attacks and have the stigma of being a particularly easy prey for malicious actors, due to the relatively low levels of problem awareness and preparedness. We argue that cyber threats pose a new challenge to reach sustainable health goals and have to be considered an imminent part of all healthcare development strategies. Cyber threats in the healthcare sector can have detrimental acute effects in times of national crisis, hybrid warfare, or international conflicts above or below the threshold of war. In peacetime and in western democracies, however, breaches of data that were processed by private or public bodies undermine the public trust in these institutions. Public awareness and scepticism therefore influence policies around the digitalization of healthcare, and this consequently affects the development of institutions at the frontline of xvihealthcare and achievement of sustainable development goals. The chapter further discusses the relationship of working towards sustainable health goals, public trust and data security with the example of the Estonian e-health system, where leading principles such as cyber security, transparency, and patient’s data autonomy are prioritized.SustainableWork Ability during Midlife and Old Age Functional Health and Mortalityby Subas Neupane and Clas-Håkan Nygård Background: Sustainable work ability is a multifaceted concept that involves the matching of the needs and abilities of the individual with the quality of work. Good work ability during a work career is one of the potential indicators of sustainable work ability and employment, as it requires a good balance between individual resources and work demands. We aimed to study the developmental pathways of work ability during midlife until retirement and its impact on functional health in terms of mobility limitations in old age using longitudinal data on employees in a large amount of blue- and white-collar occupations. Furthermore, we studied the difference in survival among people in different trajectory groups. Methods: Questionnaire data on work ability, working conditions, lifestyle, and physical functioning of middle-aged municipal employees (n = 2918) were linked with registers on retirement and all-cause mortality. Perceived work ability was measured as the current work ability compared with the lifetime best in a score of 0 to 10. The trajectory of work ability was analyzed by using growth mixture modeling in 16 years of follow-up data. Mobility limitations as an outcome was defined using nine items related to physical mobility tasks. Trajectory membership of work ability was used as a predictor of mobility limitation after 12 years using generalized linear models. Cumulative hazard curves for mortality by trajectory group were calculated. Results: Three distinct trajectories of work ability emerged. The majority of the participants (65%) had good work ability, which is here defined as sustainable work ability, 25% having L-shaped decreasing work ability and 10% having U-shaped decreasing work ability. Demographics, lifestyle factors, morbidity, and physical workload-adjusted models shows that L-shaped (Incidence rate ratio (IRR) 1.24, 95% confidence interval (CI) 1.18–1.30) and U-shaped (IRR 1.37, 95% CI 1.28–1.47) work ability trajectory membership was strongly associated with a higher risk of mobility limitations in the next 12 years of follow-up. The cumulative hazard for all-cause mortality was highest among those in the U-shaped decreasing work ability trajectory group. Conclusions: Those with a sustainable work ability during midlife showed a lower risk of mobility limitations and better survival compared xviito those with decreasing work ability. These findings highlight the importance of sustainable work ability throughout the working career as well as the need for early identification of workers with diminishing work ability and need for workplace interventions to help to promote an extended working career as well as a healthy old age.Global Health Determinants and Limits tothe Sustainability of SustainableDevelopment Goal 3Eduardo Missoni1. IntroductionThe Millennium Declaration, signed by all Heads of State in September 2000,attempted to reaffirm a human-rights-based approach to development, with theliberation of the whole human race from need as one of its main goals (UN 2000).The Declaration proclaimed equality, freedom, solidarity, tolerance, respect for natureand shared responsibility as “fundamental values”; it also recognized the unequaldistribution of common goods and the costs of globalization (UN 2000).In order to translate the Declaration into a more operational instrument, it waslater decided to identify the Millennium Development Goals (MDGs) that wouldmake it possible to verify the progress of the development agenda. The originalpurpose of the MDGs was to go beyond the narrow paradigm of growth and focus onhuman, sustainable and equitable well-being. However, the conventional economicconcept of development prevailed, with economic growth set as the primary force forpoverty reduction (Vandemoortele 2010). Emphasis was placed on the identificationof a limited number of relatively narrow targets and indicators, rather than on theneed for deeper social transformations, almost entirely neglecting issues such asinequality and discrimination (Teichman 2014). The MDGs and the related targetsset for 2015 lacked a systemic vision, and did not take the social, economic andenvironmental determinants of people’s living and working conditions into account,or issues such as equity of distribution and access to resources (Fehling et al. 2013;Teichman 2014).The MDGs focused exclusively on poor countries and reflected an idea of“development” pertaining only to development aid, involving high-income countriesonly as “donors”. Indeed, low-income countries were scarcely involved in the process(Fehling et al. 2013).In view of the 2015 deadline, in June 2012, the United Nations Conference onSustainable Development “Rio +20”, recorded a general consensus on the need for newglobal objectives for “concrete measures that accelerate implementation of sustainabledevelopment commitments” (UN 2012, p. 6), and initiated the inter-governmental1process for the identification of new, truly global Sustainable Development Goals(SDGs). The result of that process was the Agenda 2030 for Sustainable Development,adopted on 25 September 2015 by the Summit of Heads of State and Government,convening in New York, by the United Nations (UN 2015).In the traditional definition, sustainable development “meets the needs of currentgenerations without compromising the ability of future generations to meet theirown needs” (WCED 1987). Thus, sustainable development involves, on the one hand,the use of renewable resources and strict environmental protection, and on the otherhand, the ability to ensure that human progress (first and foremost, the improvementof the living conditions of the populations) lasts over time.The introduction to the ambitious Agenda 2030 affirms the “historic” dimensionof the agreement, which commits governments to the adoption of a set of 17“indivisible” objectives and 169 universal targets: to end poverty “once and for all”by 2030; to combat inequalities; to ensure lasting protection of the planet and itsresources; to create the conditions for “shared prosperity” and “sustainable, inclusiveand sustained” growth (UN 2015).The new Agenda is not without contradictions. The achievement of “Sustainable,inclusive and sustained” economic growth, one of the pillars of the Agenda 2030(UN 2015), is a conceptual oxymoron (Kopnina 2016; Spaiser et al. 2017).Inside the planetary boundaries that define a safe operating space for humanity,“sustained” growth, with unmodified production and consumption patterns, is notcompatible with sustainability. Almost fifty years ago, the first Report to the Clubof Rome indicated the existing “Limits to growth” and called for “the initiation ofnew forms of thinking that will lead to a fundamental revision of human behaviourand, by implication, of the entire fabric of present-day society” to avoid “the tragicconsequences of an overshoot” (Meadows et al. 1972, pp. 185–196). The forecastof a rapidly approaching global crisis based on mathematical models was recentlyconfirmed, based on more solid data (Turner 2014). The current COVID-19 pandemic,and its global health, social and economic consequences, seems to be a dramaticexpression of that forecast.Nevertheless, the adoption of the “Agenda 2030 for Sustainable Development”(UN 2015) could still open a new phase in development policies in the global contextof increasing complexity and unprecedented challenges, particularly as it stresses theinterrelations between the different goals and their indivisibility.Indeed, it was also suggested that health should be adopted as the main, if not thesole, goal of the sustainable development agenda, highlighting that health cross-cutsall phases of human life and people’s individual and collective experience, such as2education, work, gender balance, the distribution of wealth and access to resources,social protection, quality of the natural environment, capacity for self-determinationand the quality of democracy. “Health is a dramatic and early indicator of theperformance of other indicators, and equity in health measures the quality and extentof citizenship attributed to individuals in a society” (OISG 2014). In the same way,inequality in health is a mirror of all other inequalities, as well as constituting a“common danger”, as stated in the WHO Constitution (WHO 2014).Sustainable Development Goal 3 is to “ensure healthy lives and promotewell-being for all at all ages”. SDG 3 targets have been identified to measure thesuccess of implemented policies and strategies. Among the nine health targets, the firstthree concern maternal mortality, infant mortality and the control of certain infectiousdiseases (primarily HIV/Aids, tuberculosis and malaria) and reflect previous MDGs.The new agenda adds targets for non-communicable diseases, substance abuse, deathsand injuries from road traffic accidents, universal access to reproductive health-careservices, universal health coverage (UHC), and deaths and illnesses from hazardouschemicals and air, water and soil pollution and contamination. Finally, four specificactions have been identified, in particular (a) to strengthen the implementation ofthe “World Health Organization Framework Convention on Tobacco Control”; (b)to support the research and development of vaccines and medicines for developingcountries, and ensure access to essential medicines and vaccines; (c) increase healthfinancing, and the recruitment, development, training and retention of a healthworkforce in developing countries; (d) to strengthen the capacity of all countries forearly warning, risk reduction and management of national and global health risks(UN 2015).Although the challenge of sustainability is global, national health systems willbe confronted with it based on the very different socio-economic conditions andexpectations of their populations.The achievement of UHC has been indicated as “the centrepiece of goal 3 . . .This is the one target that, if achieved—or let’s say when achieved—will contributeto all the others” (Ghebreyesus 2018). UHC has been defined as universal access tothe health services people need, when and where they need them, without financialhardship, including the full range of essential health services, from health promotionto prevention, treatment, rehabilitation, and palliative care (WHO 2020c).It is generally accepted that universal access to quality care plays an importantrole in the improvement in population health and the reduction in health inequalities.In this sense, universal coverage is considered to be a particularly well-suited objectiveto address the complexity of the challenges facing health systems (Franklin 2017).3Among others, health systems’ effectiveness and sustainability, i.e., the ability to takecare of the needs of today without compromising the ability to provide for thoseneeds in the future, is affected by a wider range of societal determinants beyondnational boundaries.Global power and processes may seriously undermine success, interfering withhealth systems’ main functions, increasing demand or debilitating offers.The acceleration of globalization and the hegemony of the neo-liberal ideologyled to the progressive deregulation and liberalization of trade regimes, extensiveprivatization and the scaling back of the State. These processes have intensifiedthe commodification and commercialization of vital social determinants such ashealth and social services, water and electricity. Unhealthy products are aggressivelymarketed by global industries (tobacco, alcohol, pesticides and other chemicals,processed foods and beverages, etc.). Environmental deterioration is also a resultof the dominant economic model, which also heavily impacts labour and workingconditions (CSDH 2008).Health no longer depends solely on the specific situation of the country wherepeople live but is largely determined by global forces acting outside the control ofindividual states, becoming an issue of foreign policy, global security, internationaltrade, the overall sustainability of development, democratic governance and humanrights (McInnes and Lee 2012).Adopting Universal Health Coverage as a main focus, this chapter analyzes SDG3’s feasibility and sustainability using health system components as a frameworkto understand how global determinants interact with each component, affectingthe functioning and sustainability of the health system as a whole. It concludesby arguing that, without an urgent paradigmatic shift in the current developmentmodel, the attainment of SDGs, and, specifically, the sustainability of SDG 3 and its“centerpiece” UHC will be at stake.2. Health Systems’ FunctionsThe World Health Organization (WHO) defined health systems as “all theactivities whose primary purpose is to promote, restore and maintain health” (WHO2000, p. 5). This includes health care as well as efforts to positively influencedeterminants of health. This conceptualization of health systems goes beyond theboundaries of the healthcare system, including policies and interventions oftenoutside the direct competences of the health authorities, such as food accessibility,quality and safety, road safety or environmental control.4Based on the approach proposed by the WHO (2000; 2007; 2010b), the coreobjectives of health systems may be summarized as: (a) protecting and improving thehealth of the population they serve and reducing health inequalities; (b) respondingto people’s non-medical expectations and enabling participation in decisions thathave an impact on their health and health systems; (c) protecting individuals fromthe risk of financial hardship due to the costs of health services through risk-poolingmechanisms, ensuring fairness for individual contributions and equity in access toservices, i.e., access to and coverage of effective health interventions according toneeds; (d) ensuring the best use of available resources to reach the aforementionedthree objectives.While the latter three objectives are specific to the healthcare system,the attainment of the first objective—protecting and improving health—relies onlypartially on healthcare and requires extending action, and even our understanding ofa health system, to a system for health, i.e., beyond “activities whose primary purposeis to promote, restore and maintain health” (WHO 2000, p. 5)., to include all thepolicies and activities that have an impact on human health, thus also challengingthe healthcare system, and its capacity to provide UHC, as will be discussed below.Regardless of how they are organized, to achieve their goals, all health systemshave to rely on some basic components: (a) leadership and governance; (b) humanresources; (c) medical products and technology; (d) mobilization and allocationof finances; (e) service delivery. The components originally identified in theWorld Health Report 2000 were later summarized in the WHO Health SystemsFramework, capturing information as an additional cross-cutting “building block”of increasing importance in supporting the overall functioning of the system(WHO 2007). The relationships among the six building blocks and their connectionwith the objectives of the health system are represented in Figure 1.It is well-known that “health systems are subject to powerful forces andinfluences that often overwhelm the rational formulation of policies” (WHO 2010b).Among others, “these forces include a disproportionate focus on specialist care,fragmentation into a multiplicity of competing programs, projects and institutions,and the pervasive commercialization of health care into inadequately regulatedsystems” (WHO 2010b, p. 1).5Fig.1 Health systems’ building blocks and goals.(WHO 2000; Missoni et al. 2019, modified)Health Systems’ Building blocks Objectives of the Health System(includes all public policies)InformationHealth-care SystemLeadership /GovernanceEfficiencyHealthResponsivenessEquity in accessFair financialcontributionService deliveryFinancingHuman ResourcesInvestment andmedical productsFigure 1. Health systems’ building blocks and goals. Source: Modified from(WHO 2000; Missoni et al. 2019).Indeed, the efficiency (appropriate use of resources) and effectiveness(achievement of objectives) and, ultimately, sustainability, of health care systems areput to the test by many forces and phenomena, which also require interventions andpolicies that are located outside the health system and often beyond the exclusivecontrol of national authorities. In the following sections, we will focus on thoseinteractions.3. Determinants That Affect Steering and GovernanceNational health policies are influenced by international policies and transnationalforces acting at different levels. Structurally or economically weaker states andeconomies are more susceptible to such influences and less prepared to deal withthem. In the 1980s, international financial institutions (mainly the InternationalMonetary Fund and the World Bank) imposed Structural Adjustment Plans (SAPs)on a large number of indebted countries, which entailed, among other things,a drastic reduction in public spending, the dismantling of universalist health systems,the privatization and commercialization of health services and the introduction of userfees—a real “tax on disease” (Geddes 2018, p. 35)—which had disastrous effects interms of reduced access to services, exclusion of the weakest and the impoverishmentof families. In more recent years, similar macroeconomic measures have beenimposed by international and supranational bodies in more advanced economies aswell, which were affected by the economic crisis, causing the impoverishment of largesections of the population (Kondilis et al. 2013). These measures contribute, among6other things, to the fragmentation of health systems, making their management morecomplex and increasing their costs (Lister 2008; Geddes 2018).In Official Development Assistance (ODA)-recipient countries, health policiesand priority setting are strongly influenced by earmarked resources and donorconditionality, which often do not take the needs of partner countries into account(Biesma et al. 2009).4. Determinants That Affect Human Resources and Access to Medical Productsand TechnologySeveral global determinants influence the availability of human resources andaccess to medical products and technology.The inadequacy of health workers’ training in relation to the needs of thepopulation has been recognized since the 1970s. The training of health personnelshould not start from pathology, but from the context that generates disease, “fromreality and not from theory, from the living society and not from the study of acorpse” (Maccacaro 1971, p. 377). With a few exceptions, medical faculties continueto follow what the Brazilian pedagogist Paulo Freire defined a “banking” educationalapproach (Torre et al. 2017), providing “information, or rather notions, detachedfrom the context of real medicine that inevitably takes place more and more in theterritory, outside the hospital” (Stefanini 2014). The World Health Report of 2008also highlighted “hospital-centrism” among the problems at the root of the failure inachieving the health-for-all goal (WHO 2008). Practice in medical studies is mainlybased on the observation of a hospitalized individual in a “horizontal” position, a“patient” in bed (Missoni 2018), and in a context too often socially and/or culturallyalien to the social reality in which people “are born, live, work, grow old and die”(CSDH 2008, p. 26).From the beginning of their career, future medical professionals are introduced tothe logic of a globalized social model, which is profit-oriented and serves the interestsof the dominant class (Stefanini 2014). Moreover, the standardization of skills andlearning objectives (disproportionate focus on specialist curative care, high complexity,technological sophistication, etc.) respond to healthcare models that are scarcelysustainable even in middle–high income countries and are accessible elsewhereonly to high-income population groups. Such an approach is a bad investment forlow-income countries that already lack essential human resources. On the one hand,it produces health workers who are incapable of “usefully becoming part of an urbanor rural community, of taking care of it, of understanding the problems of its illnessand of defending its right to health” (Maccacaro 1971, pp. 377–382), with a training7clearly detached from the local needs. On the other hand, the standardization oftraining across countries may have the unintended consequence of helping withprofessional migration across national boundaries (Frenk et al. 2010).The main drivers of brain-drain include push (low level of income, poor workingconditions, the absence of job openings and social recognition, oppressive politicalclimate) and pull (better remuneration and working conditions, prospects for careerdevelopment, job satisfaction, security) factors; however the latter leverages globallystandardized training, which tends to produce “fit for export” health personnel.Indeed, health workers and, in particular, doctors, who are not prepared andunmotivated to serve in their own communities, will seek work elsewhere—first inlarge urban centers and then abroad—to obtain the kind of professional integrationthat requires their skills and meets the aspirations suggested in their medical studies,according to the globalized stereotype of the successful doctor (Missoni 2018).Health workforce “brain drain”, is also fueled by “import” agencies fromhigh-income countries lacking human resources, often bypassing the norms thatsome of those countries have adopted based on the WHO global code (WHO 2010a).Healthcare-related trade policies and agreements have also promoted the migrationof health professionals from the public sector to the private sector, and abroad.Medical products and technologies are key resources for the health systems,but global determinants may affect their availability and affordability, as the followingexamples illustrate.While basic research is still largely generated in universities and public researchinstitutes, thanks to private funding, the research and development of biomedicalproducts and devices are essentially in the hands of the transnational corporate sector,which invests only if a return on investment can be predicted, without taking healthneeds and health burden into account. As a result, only 10% of global health researchspending is allocated to health conditions that account for 90% of the disease burden.Between 2000 and 2011, only 1% of the new active ingredients on the market were forneglected diseases (Pedrique et al. 2013). Thanks to the contribution of internationalinitiatives and product development partnerships, there has been some progressin recent decades, especially for malaria, but very limited or no progress for otherneglected diseases, such as dengue fever, Buruli ulcer, trachoma, rheumatic fever,or typhoid fever (Cohen et al. 2010).The price of medicine remains the largest obstacle to access to care. Drugsand other medical products represent the largest public expenditure on health afterpersonnel costs in many low-income countries, and the expense is a major cause ofhousehold impoverishment and debt (WHO 2020b).8Numerous patent-protected lifesaving medicines of proven efficacy are marketedat a high price, unaffordable for most of the people and healthcare systems inlow-income countries. The global system of protection of intellectual property rights(IPR) may contribute to price increases and reduced access to medicines and vaccines(Smith et al. 2009). In the interest of public health, flexibilities under the Trade-RelatedAspects of Intellectual Property Rights (TRIPS) agreement—such as compulsorylicensing and parallel import—allow countries to gain access to medicines that, inother countries, may still be under patent. Unfortunately, there is still reluctance toimplement these flexibilities due to concerns about the reactions of trade partnersor a lack of the administrative, legal and/or productive capacity to adopt suchan approach, which is also opposed by transnational pharmaceutical companies(Kerry and Lee 2007).Prices may come down when the patent expires, and competition and/orgeneric products emerge. However, at that point, the transnational pharmaceuticalindustry often adopts sophisticated “lifecycle management” strategies. This patent“evergreening”, based on the introduction of minor changes to the formulation, allowscompanies to extend their monopoly privileges on the drug, keep prices high andremain in control of these drugs on the market. This seriously challenges the accessto affordable drugs, as it delays the generic competition without any improvement inthe efficacy of the already-patented drug (Abbas 2019; WHO 2020b).5. Determinants Affecting the Financing of the SystemThere is a correlation between the increase in health spending and increased lifeexpectancy. However, above a spending threshold of about 75 US dollars per capita,that relationship becomes unpredictable and improvements in health outcomesdepend mainly on the efficiency of the system (how money is spent) and on politicalchoices related to social solidarity and equity (Savedoff et al. 2012).In the same way, beyond a certain threshold of GDP per capita, economic growthis no longer correlated with health outcomes; rather, the inequality in the distributionof income directly correlates with disease burden (Pickett and Wilkinson 2015).The efficiency of health care systems largely depends on how funds are collected,allocated, pooled and finally used for the purchase of services.The combination of these components determines how many resources will bemade available and how efficiently they will be used to achieve the desired results.The macroeconomic framework of a country (including the quality andeffectiveness of its fiscal system) determines resources’ availability. Weaker economies9have greater difficulty in bearing the costs of their health care systems and suffer mostfrom financial crises and the imposition of international provisions (Gurtner 2010).Ideologically mandated “rigorous” one-fits-all austerity policies impose socialexpenditure “cuts”, including to salaries, maintenance costs and investments.As Geddes observes, “the undeclared objective” is to reduce the public servicessupported through the State’s tax revenues, with the purely political aim of promotingthe privatization of services, to the benefit of private capital (Geddes 2018), in averitable “assault on universalism” (McKee and Stuckler 2011).Dependence on out-of-pocket payments (OOPs) of services, introduce regressivemechanisms in financing, constitute a barrier to access to needed care and generateproblems of financial protection. There is a very strong correlation between the levelof OOPs and the incidence of catastrophic and impoverishing health expenditures,which are solely determined by the extent to which out-of-pocket payments absorb ahousehold’s financial resources (WHO 2020a).Every year, more than 100 million people end up in poverty as a result ofdirect spending on health care (Haider and Nibb 2017). When in need, peoplewithout guarantees of access to care tend to turn to the much more expensive hospitalemergency services. In addition, they tend to be excluded from health promotionand prevention activities that health services carry out.In poor resource-settings, where health care providers tend to be inadequatelypaid, user fees may constitute a major source of revenue for health workers, creatingperverse financial incentives (WHO 2020a).Out-of-pocket health spending as a percentage of total health spending is highestin lower-middle-income countries and tends to make up a smaller share of the totalhealth spending in upper-middle- and high-income countries (IHME 2019). However,even in the European Union “too many patients [ . . . ] are facing financial hardshipsas a result of healthcare costs” (Franklin 2017, p. 2) and, for some people, direct costsact as a deterrent to the use of health services or to the continuity of care they cannotafford. Others, in order to access needed care, have to cut spending on food, clothingand housing. Unfortunately, since 2009, spending on direct payments in Europe hasgrown faster than public spending, with a negative impact on the functioning ofhealth systems and the functioning of society in general, in terms of social cohesionand economic development (Franklin 2017).Fragmentation reduces health care systems’ efficiency, and systems based onthe private coverage and insurance market are the most inefficient, with the sharpestincrease in both public and private health expenditure (Unger and De Paepe 2019;Geddes 2018), which obviously makes this approach the less sustainable one.10Private insurance systems also promote over-diagnosis and induce healthconsumerism, without benefits to the public sector even in terms of waiting lists’reduction, use of services or cost reductions. Rather, cost-control is much moreproblematic in systems where different providers compete, even disregarding thenegative impact on the equity of the system (Geddes 2018; Steendam et al. 2019).In low-income countries, health services are largely dependent on developmentassistance. Unfortunately, external financing is often also volatile and unpredictable,making planning impossible. In addition, these funds are often tied to particularactivities or diseases, sometimes do not respond to local needs and nationallyestablished priorities and use autonomous management procedures and mechanismswith unnecessary duplication and increased transaction costs, generating anunsustainable administrative burden on already weak, resource-poor institutions(Missoni et al. 2019). The steady increase in the number of public and private aid actorsand their profound diversity in terms of strategies and procedures, disregardinginternationally agreed alignment and harmonization strategies (OECD 2005), furthercontribute to making aid inefficient and ineffective. Besides leading to an extreme andunsustainable fragmentation of national systems, the growing number of new privateactors and public–private partnerships, pushed by the globalization of neoliberalideology, also undermine the WHO’s authority in directing and coordinatinginternational health activities, and thus its leading role in support of nationalsystems (Missoni et al. 2019; Ruger 2018).6. Determinants That Affect Service DeliveryBoth increases in demand and insufficient or inappropriate offers may affectthe capacity of a healthcare system to provide universal access to care, and thesustainability of such a policy.6.1. DemandBesides demographic factors, the fil rouge that links multiple determinants of theunsustainable increase in illness and, as a consequence, demand is the consumerisminherent to the globalized capitalistic growth society, which is reflected in the multiple,diverse, but interconnected pathways described below.The steady increase in the world’s population and its progressive ageing areamong the main causes of increased demand for health services. Between 2015and 2050, the proportion of the world’s population over 60 years of age will almostdouble, from 12% to 22% (WHO 2018b).11Ageing not only leads to a decline at the biological level, it is, in fact, associatedwith a profound transformation of a person’s lifestyle, and often living conditions,which, in turn, may contribute to the worsening of physical and mental health.Although partly dependent on genetic factors, the health of elderly people is heavilyinfluenced by social, economic and environmental determinants, including the qualityof food, housing conditions and the consistency of family and community networks,as well as life experiences since early childhood. In this sense, the social determinantsthat affect young people today will influence the type and frequency of diseases inthe coming decades. Geriatric syndromes that characterize health conditions of theelderly, i.e., complex multimorbidity, lead to a greater demand for health care andrequire totally new care approaches (WHO 2018b).The considerable increase in the global burden from chronic diseases cannot beattributed exclusively to the ageing of the population. In fact, it affects all age groupsand almost all countries, with a much greater impact in poorer countries, whichare experiencing an epidemiological transition with a double burden of disease, i.e.,both infectious diseases and chronic non-communicable diseases. Three quartersof deaths from chronic diseases are recorded in low- and middle-income countries(Haider and Nibb 2017).While pandemics of old and new infectious diseases are seriously challenginghumanity, an “epidemic” of chronic diseases, especially heart disease and cancer,observed since Second World War, clearly parallels the globalization of the westernsocietal and lifestyle model (Kesteloot 2004).A society aiming at and measuring its success through sustained growthrequires a constant increase in consumption, no matter what is consumed andno matter the impact on the environment and health, based on the conventionalwisdom that those are the unavoidable consequences of economic development(Landrigan et al. 2018). To that end, agricultural and industrial production cyclesbecome faster, more resource-intensive and more contaminating, with the inexorableimpoverishment of natural resources and increased levels of pollution, which isthe largest environmental cause of disease and premature death in the world today(Landrigan et al. 2018).With the promise of high yields and reduced losses in the production, pesticidesand chemical fertilizers are massively promoted and used almost without control,causing contamination of the soil, water, and air, with a direct health hazard for ruralworkers and their families, and dangerous amounts of chemical residuals enteringthe food-chain, including drinking water (Kennedy et al. 2004; Landrigan et al. 2018;12Willett et al. 2019). The phases of food processing, packaging, transportation, andstorage are also significant contributors to food contamination (Rather et al. 2017).Similarly, industrial production is still widely based on the use of energy fromfossil resources, contributing to high emissions of CO2 and other greenhouse gases,and thus climatic change, as well as, in many cases, diffusion in the environmentof many other dangerous contaminants, with a direct impact on the health of thepopulation and an increase in health care expenditure in neighboring provinces(Zeng and He 2019). Climate change, indissolubly linked to the dominant productionand consumption model, has an impact on health, with multiple interactions andpredictable, potentially catastrophic, irreversible epidemiological transformations(Watts et al. 2017).Extremely aggressive market strategies further push consumption. Worldwide,supermarkets’ shelves are full of harmful food (processed foods with added sugar,salt, preservatives and colorants; high-calorie drinks; etc.), alcohol and tobacco,and other unhealthy or otherwise potentially harmful consumer products (such ashome and personal care), which all contribute to the dramatic increase in chronicdiseases such as obesity, metabolic diseases (first of all diabetes), respiratory diseases,cardiovascular, neoplastic, and neurodegenerative and mental illnesses (Kennedyet al. 2004; Landrigan et al. 2018; Willett et al. 2019).In turn, consumption produces waste and a variety of pollutants, which, in mostcases, are not optimally disposed of. Among others, the presence of microplastics inthe food-chain, including treated tap- and bottled water, have raised considerableconcerns regarding their impact on human health (WHO 2019).Overall, environmental factors account for between 25% and 33% of the globalburden of disease. A total of 83% of deaths are mediated by environmentalfactors. Carcinogenetic chemicals can now be found at every level of the foodchain, in soils, groundwater and air emissions, and are widespread in a myriadof household and personal care products to which people are exposed every day(Haider and Nibb 2017).The impact of pollutants on health is not limited to current generations. Besidesthe environmental consequences of the unsustainable exploitation of natural resourcesand the pollution of land, water and the atmosphere, many widely disseminatedpollutants have been shown to produce epigenetic changes which are transmittedfrom one generation to the other, putting the health of future generations at risk(Skinner et al. 2010).13The ongoing commodification of water is the subject of growing concern inrelation to water security, as well as quality- and water-related diseases, besides themaintenance of an unequitable status quo of inaccessibility. (Brisman et al. 2018).Mental and relational pathologies (depression, suicide), and physicalpathologies deriving from the use of new technologies (reduced physical exercise,pathologies of postural origin) are associated with globalized changes in lifestyle,including “behavioural addictions” associated with “excessive use of the internet,computers, smartphones and other electronic devices” which are also increasing(WHO 2015, p. 5).The direct and indirect impact of the ever-increasing global exposure toelectromagnetic fields on human health is widely underestimated and is a matterof increasing concern, calling for the adoption of severe precautionary principles(Bortkiewicz 2019).Besides the pathological effects arising from the use of new technologies,the global expansion of the Internet has an additional impact on the increase inhealth demand. Social networks represent an easily accessible market of hundredsof millions of users through direct-to-consumer advertising of the improper orillegal use of often counterfeit medicines, with considerable health risks and aninevitable increase in health expenditure. Direct advertising is the fastest growingform of pharmaceutical marketing. Although only legal in the United States andNew Zealand, online forms of interaction now allow legal restrictions to be violatedeverywhere (Liang and Mackey 2011).Through disease-mongering strategies, i.e., creating patients, offering a distortedperception of the severity of a condition or presenting a physiological condition aspathological, the pharma industry induces the unnecessary consumption of drugs,contributing to the increase in health expenditure (Doran and Henry 2008).The health care system itself also contributes to its own unsustainability, beingone of the causes of the spread of antibiotic resistance, although 80% of antibioticconsumption happens in the livestock industry. The General Assembly of the UnitedNations, in 2016, warned against the potential re-emergence of diseases kept undercontrol for decades, and the risk of new catastrophic epidemics (IACG 2019).6.2. The OfferIncreased demand may also come from within the health care system. It iswell known that, in the health sector, the increase in supply generates demand,particularly in the absence of control mechanisms and in health systems mainlybased on private care. Particularly in developing countries, health care systems are14highly fragmented and governments, which are mostly only in control of the publicsector, are not able to create appropriate mechanisms to regulate the private sector’sactivities and performance. Experience in the Americas shows that fragmentationleads to difficulties in access to services, the poorer technical quality of services,the irrational and inefficient use of resources, unnecessary increases in productioncosts, and low user satisfaction with the services received (Montenegro et al. 2011).On the other hand, health management in developing countries is inspired bythe theories and practices adopted in high-income countries, and tends to reflectelements which are intimately linked to the technological, institutional and culturalcharacteristics of those countries. Management and governance systems are oftenimposed from above and are not consistent with the local context, while the “western”model, dominated by neoliberal policies, has become the universally adoptedstandard. In addition, we have been witnessing, for some time, a generalized attemptto transfer the logic, culture and managerial tools of private enterprises to the publicsector, based on the unproven principle that market forces tend to generate betterresults than bureaucratic and hierarchical mechanisms (Fattore and Tediosi 2011).Health, and health systems, is increasingly at the mercy of market dynamics.The commercialization of health care further contributes to the fragmentation ofhealth systems, with resources being taken away from the public system to theadvantage of the private system, with obvious discrimination in terms of the access toand quality of services, and even the exclusion of important sections of the populationfrom access to both curative and preventive care (UNRISD 2007).The lack of, or limited access to, adequate health care services (sometimeswith paradoxical situations where family income is insufficient to afford privateinsurance, and not low enough to receive public assistance), pushes populationgroups with sufficient economic resources to travel for the purpose of receivingmedical care at lower costs, engaging in so-called “Medical Tourism”. Whilemedical tourism is seen as an opportunity for economic returns in the recipientcountries, eventually, many authors would agree that, for those countries, healthtourism is a source of increased inequalities, possible overall healthcare cost increasesand an additional push-factor for the migration of the health workforce from thepublic to the private sector, even without considering the risks for patient-tourists(related to travel, medical–surgical intervention, the course and post-operative care)(Hopkins et al. 2010).It is paradoxical, and ethically unacceptable, to consider medical tourism as anopportunity that should be encouraged to reduce the national health expenditure ofthe originating countries, arguing, for example, that “If only 10 percent of the top1550 low-risk treatments were performed abroad, the U.S. health care system wouldsave about $1.4 billion annually” (Herrick 2007, p. 28), without worrying about thenegative effects on the destination health care systems.While technological innovation can contribute, among others, to promotinghealthy behaviour, supporting home care, and facilitating more accurate diagnosesand better therapeutic responses, it is not always real progress and can createsustainability problems. Industry introduces new technologies responding toexpectations of return on an investment, independently from the real therapeuticadvantage they may offer (Thimbleby 2013). The health sector is also often preyto “planned obsolescence” as a market strategy by which manufacturers inducethe replacement of equipment with new models that bring nothing substantive interms of diagnostic or therapeutic results, aiming instead to create dependence onaccessories and consumables (Rosenthal 2014). Most innovations tend to increasecare costs, rather than reduce them, without a parallel increase in performance(Geddes 2018). What is too-often lacking is good management of existing technologyand an adequate maintenance culture, an often-forgotten aspect in infrastructuraland technological aid projects in low-income countries.Over-prescription is another cause of increases in health care costs.Geddes (2018), for example, warns against “periodic check-ups”, which areoften promoted as part of well-designed market strategies in the biomedicalindustry, but have “no effect in reducing diseases and deaths from either canceror cardiovascular disease”, rather leading to an increase in diagnoses and“incidentalomas”, with consequent risks related to further investigation.The abuse of medicine, technologies and services, including ineffective orinappropriate use, is also linked to the culture and choices of prescribers (often underthe marketing pressure of manufacturers and pharmaceutical representatives), patientrequests (induced by misleading and increasingly pervasive advertising), conflictsof interest, fragmentation of levels of care leading to the repetition of clinicalinvestigation, and remuneration criteria for facilities and professionals (Geddes 2018).7. Making Health Systems SustainableThe incompatibility between the planet’s finite space and resources and theconsumerist imperative of our global growth-society, as well as the impact onthe health of the latter and the need for “degrowth”, have been widely described(Missoni 2015).Despite its contradictions (such as the oxymoron of “sustained sustainablegrowth”), which should be corrected, the implementation of Agenda 2030 and its16universal sustainability goals represents an opportunity to avoid disaster. Indeed,pursuing “health and well-being for all and for all ages” (SDG 3) could make afundamental contribution to the achievement of several other SDGs, including thatof economic growth (Kieny et al. 2017). However, health-for-all in general, and theachievement of “universal access to essential quality healthcare services” in particular,are subject to the achievement of many other SDGs, where progress seems to behalting (UN 2019).Despite the extraordinary international commitment, the necessary change indirection cannot yet be perceived. In the previous sections, we have tried to highlighthow global determinants interact with the different components of national healthsystems, interfering with their sustainability and the achievement of the UHC goal.Below, some corrective actions are identified to promote the resilience of the system.7.1. Steering and GovernanceIntervention in the global determinants that act on the governance of the healthsystem requires a solid alliance between public stakeholders, through all levels of thesystem, from the local (civil society organizations and grassroot movements), to thenational and supranational (e.g., the EU), to the global (international institutions, inparticular the WHO), both for the promotion of good practice and the prioritizationof health in all public policies (economic, industrial, agricultural, social, etc.), whenneeded through regulatory interventions to control market forces that push in theopposite direction (Missoni 2015).To this end, the WHO should be re-empowered and use all its authority topush public health needs and priorities in the political agenda of other sectors andinitiatives, e.g., in trade negotiations, at both global and regional levels (Missoni2015). The systematic application of the Health Impact Assessment (HIA) (WHO1999) to all public policies would allow for the timely correction of legislative projects,plans and programs that do not respect that priority and may have negative healthoutcomes. Today, HIAs are implemented mostly as a section of the environmental,social and health impact assessment (ESHIA) of industrial projects (e.g., in theextractive industry), and are mostly implemented to meet a regulatory or statutoryrequirement. Instead, policy proposals should be subject to HIA with a wider societalscope, adopting a social view of health approaches and being used as a mechanismto address the potential health inequities that they may generate (Harris-Roxas andHarris 2011).177.2. Ensuring the Right Human Resources and Access to Medical Products and TechnologyIt is essential to radically rethink health workers’ curricula. They should beexposed to community health from the very beginning of their studies, and madeaware of the role of socioeconomic and related social factors in shaping health. Theirknowledge and experience should be consistently linked and relevant to local realities,as well as inspired by values of social solidarity and service, with people at thecentre. Health professionals should be trained in the use of socially, culturally andeconomically appropriate technologies, and be guided by the needs of the populationand the early correction of determinants with a negative impact on health.Applying the WHO Code for the International Recruitment of Health Personnel(WHO 2010a) to address the shortage of health workers and their distribution willnot be enough in the absence of an in-depth review of policies and investments aimedat aligning health workers’ competences (knowledge, experience, motivation, values)to the context and needs of the population they are intended to serve, rather thaninvesting in, and even increasing resources for, the perpetuation of a flawed system.Similarly, it will be necessary to find the right incentives for the researchand development of technologies to serve the health of the population, ratherthan the economic interests of investors. The market follows the consumer, and“corporate social responsibility” also responds, to a large extent, to consumers’ choices.In the provision of health care, the main customer is often the State. In this case,the choices that decision-makers at different levels of the health system will be ableto make in order to orient and regulate medical consumption and innovation will beparticularly relevant.7.3. FinancingAlthough there is no single formula for universal coverage, ensuring fairnessin individual contributions and equity in access to services are essential to protectindividuals from the risk of financial hardship due to the costs of health services.To ensure fairness, individual contributions should be based on progressivity, i.e.,increasing in rate as the base increases with the economic capacity of the contributor.This is a common characteristic of many fiscal systems, thus of health care systemsthat are financed through general taxation, an approach that many countries withlarge sectors of informal economy and/or weak fiscal systems cannot adopt, meaningthat they need to recur to alternative mechanisms and sources to finance their publichealth care systems.Besides a stable increase in the resources allocated to the health system, universalaccess to care requires greater use of advance payment mechanisms and a parallel18reduction in the dependence on out-of-pocket payments for services, which aretypically regressive and thus unfair (Haider and Nibb 2017). To increase efficiency,reduce inequalities and promote equity, it will be mandatory to reduce systems’fragmentation, merging collecting institutions, and, above all, pooling risk as widelyas possible across the population.The quality of financial and administrative management systems is also afurther element in this direction (Evans and Antunes 2011). Stepping away fromhealthcare privatization policies is also essential to reduce inequality and costs,increase quality, efficiency and public control, and optimize the use of the healthworkforce (Steendam et al. 2019).Certainly, to be sustainable, health systems need to be guided by long-termstrategies that include investment in the development of adequate managerialapproaches, simplification of processes, the appropriate use of ICT and a strengthenedadministrative capacity, in order to free up energy and human resources for carefunctions, reduce administrative complexity, and ensure proper monitoring ofactivities and costs and a reduction in waste (Geddes 2018). In this sense, integratednational health systems allow for considerable economies of scale and greaterefficiency, in this as well as in terms of planning, procedural and technologicalstandardization, and the centralization of procurement (Montenegro et al. 2011).Given the globalization of health industries (pharmaceutical, insurance, etc.),global regulatory mechanisms and coordination are equally essential (Geddes 2018).In countries where external aid plays a significant role, it is fundamental thatfunding, in addition to being increased, becomes more predictable (with long-termcommitment), less fragmented and respectful of the well-known principles of aideffectiveness (ownership, alignment and harmonization) (OECD 2005). When feasible,General Budget Support initiatives and Sector-Wide Approach programs with theestablishment of joint funds in support of sound national health plans are among thebest options (Missoni et al. 2019).7.4. Health ServicesThe response of the health care system to demographic changes (populationgrowth and ageing) can only be through adaptation. The increased demand derivingfrom the ageing of the population, with its corollary of chronic and multi-morbiditydiseases, calls for a rethinking of the model of care, and even of socialization, whichcan be implemented in the short- to medium-term. The active social integrationof disabled and elderly people should be promoted as much as possible. In moreadvanced countries, experiences which are alternative to the conventional social19organization (e.g., unifamilial home), such as extended families, life-communities,the sharing of living spaces (co-housing) and resources, offer opportunities toreconsider intergenerational experiences of solidarity, which are valid alternativesto the hospitalization and institutionalization of people with reduced autonomy(Missoni 2015). Naturally, such an approach also requires an investment in thedevelopment of new skills.People and communities, with their own specific needs and problems, shouldbe the focus of any system whose goal is health and wellbeing. A people-centredapproach implies framing access to health care as a right and requires changes inboth culture and society.Universal access can only be guaranteed through a Primary Health Careapproach, which was already indicated in 1978 as the strategy to ensure “Health for allby the year 2000”, but which was immediately opposed and replaced by the selectiveapproach that has contributed everywhere to weakened health systems (Missoniet al. 2019). Primary care must link the community and the rest of the health caresystem, i.e., it must be the basic element of a care system, which links social protectionand support to health care and is organized according to well-connected levels ofcomplexity and intensity of care that are able to provide appropriate responses atthe most appropriate level. Pathways of integration among different policy fields,including health, social protection and urban regeneration, have been promoted andencouraged to address societal changes, particularly in more deprived urban areas(De Vidovich 2020). Linking the health care system to community social networks(volunteering, self-help groups, self-managed centers, etc.) and involving the patientas an active player in the care processes is also part of the Chronic Care Model (CCM),and its further development also responds to this need (Wagner et al. 2001).In many countries, primary care is a natural hub for the integration of Traditionaland Complementary Medicine (T&CM) with national health systems. This integrationhas been advocated since the 1970s to improve primary care access and healthoutcomes by increasing the availability of services as an additional point of contact anda clear contribution to pathways toward UHC (Lee Park and Canaway 2019). However,in many cases, a lack of support or frank opposition from central governments,institutions, medical organizations, and the biomedical industry represented anobstacle in that direction. The considerable worldwide use of T&CM, both inindustrialized countries (Unites States, 42%; Australia, 48%; France, 49%; Canada,70%) and less advanced economies (Chile, 71%; Colombia, 40%; up to 80% in Africancountries), should suggest the need to bring traditional medicine “into the mainstreamof health care, appropriately, effectively, and above all, safely” (WHO 2018a, p. 1).20Today the connection between primary care and a higher level of complexitymay take advantage of new information and communication technologies (e-health,m-health, big-data, social networks, etc.); however, these also require guidance,regulation and organization within the health system for their optimization.The digital revolution of the health system is, in fact, a “Tsunami” directed by“numerous, powerful and intelligent forces and actors” with an “immense thirstfor technological and economic conquest” (Comtesse 2017). Health systems are notprepared to face this challenge. Due to its transnational dimension, the responseneeds a phenomenal commitment to global analysis and direction. In general, asystemic approach to new technologies is still missing almost everywhere, and theprojects described in the literature refer almost exclusively to pilot experiences thatseem to lack systematization. The WHO itself states that: “For eHealth to play its fullrole in helping health systems achieve UHC a sound legal framework is required”,which is obviously still missing (WHO, p. 6).In general, the focus must be shifted from treatment to primary prevention,from the hospital to the community—now also the virtual one—where the diseaseoriginates. Therefore, first of all, policies and interventions are needed aimed atimproving the daily living and working conditions of the population (housing,workplace, public spaces, transport, recreational and sports facilities, etc.), as well aspolicies aiming to “tackle the inequitable distribution of power money and resources”(CSDH 2008, pp. 108–109). Interventions at the community level involve localand national responsibilities and public policies, which should prioritize healthand inevitably involve multiple sectors and authorities outside the health sector.Nevertheless, the role of the choices made at the international level to promote andsupport national and local initiatives should not be underestimated.The control of internet-mediated activities on health and health consumptionnecessarily requires international synergies, as national laws are easily circumventedon the web, making global measures urgent (Liang and Mackey 2011).The primary (i.e., immunization) and secondary prevention (i.e., screening andearly detection) programs offered by health services are of great importance. However,policy decisions should always consider risks in terms of safety, effectiveness andpossible risks.In the long-term, the reduction in demand due to chronic diseases can onlyderive from interventions for systemic determinants, for example, through laws andregulations that impose (e.g., through restrictions, taxes and other disincentives)the internalization of the social costs of production cycles, practices, services andproducts that are harmful to health, which are otherwise transferred to the community,21while incentivizing the accessibility (wide availability, lower costs, etc.) of healthyproducts and services. Unfortunately, this type of intervention clashes with stronginterests and requires considerable courage and political will. Health educationcampaigns aimed at promoting the change in individual behaviors (stopping smoking,reducing the consumption of alcohol or sugar, doing more exercise, consuminghealthy food, etc.) are an easier alternative (politically and socially less problematic),but considerably less effective (Swinburn et al. 2011). At the local level, changesin consumption patterns and behavior can greatly benefit from the initiatives ofsingle groups and communities. Instead, at a global level, only a strong connection,through national and transnational networks of civil society organizations, and theircooperation with international institutions, particularly the WHO by mandating “thedirecting and coordinating authority on international health work”, will generate thealliance which is necessary to combat the “globalization of unhealthy lifestyles” andoppose “the commercial interests of powerful economic operators” (Chan 2013).8. ConclusionsDespite good intentions, the achievement of SDGs seems to move further awayevery year: “At the current pace, around 500 million people could remain in extremepoverty by 2030. Global hunger is on the rise. Violent conflicts, climate change,gender disparities, and persistent inequalities are undermining efforts to achieve theSDGs” (Steiner 2019, p. 1). The COVID-19 pandemic is an additional, unprecedentedwake-up call.More than ever, the achievement of the universal and indivisible SDGs set byAgenda 2030 represents a considerable challenge for health systems worldwide.UHC is a central goal for the health sector in the wider context of SDG 3.However, the feasibility and sustainability of universal access is heavily dependenton the intertwined actions of multiple and diverse forces and determinants acting atvarious levels, with global determinants playing an enormous role. Thus, pursuing“health and wellbeing for all at all ages” will require strong intersectoral collaborationand pushing the health priority into all public policies. The success of Agenda 2030undoubtedly rests on the respect of the principle of indivisibility of the SDGs.From the examples proposed in this paper, it should be evident that the main“cause of causes” of the unsustainability of the UHC target, and of SDG 3 as a whole,is the dominant neoliberal, market-oriented societal model. As a consequence of itsindivisibility, the same overarching determinant hampers the success of the wholeAgenda 2030.22The scientists who wrote the report commissioned by the Club of Rome were“convinced that realization of the quantitative restraints of the world environmentand of the tragic consequences of an overshoot is essential to the initiation of newforms of thinking that will lead to a fundamental revision of human behavior and, byimplication, of the entire fabric of present-day society” and called for a “basic changeof values and goals at individual, national, and world levels” (Meadows et al. 1972,pp. 189–190). Today, evidence of the correctness of that analysis and forecast makesthat radical economic and social transformation imperative (Turner 2014).The (un)sustainability of the UHC target and SDG 3 may be a good indicatorof the limits of the Agenda 2030 in the absence of a paradigmatic shift toward amore inclusive, cooperative, equitable and ecological human society, where nobodyis left behind.Conflicts of Interest: The author declares no conflict of interest.ReferencesAbbas, Muhammad Z. 2019. Evergreening of pharmaceutical patents: A blithe disregard forthe rationale of the patent system. Journal of Generic Medicines 15: 53–60. [CrossRef]Biesma, Regien C., Ruairi Brugha, Andrew Harmer, Aisling Walsh, Neil Spicer, and Gill Walt.2009. The effects of global health initiatives on country health systems: A review of theevidence from HIV/AIDS control. Health Policy Plan 24: 239–52. [CrossRef] [PubMed]Bortkiewicz, Alicja. 2019. 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IntroductionIn the past few decades, there have been major improvements in the health ofthe citizens of most countries in our world. World infant mortality fell from 160deaths under 12 months per 1000 live births in 1950, to 41 in 2016. There are stillwide discrepancies between the regions with the highest infant mortality (Westand Central Africa; 95 per 1000 live births) and the lowest (Western Europe;4 per 1000 live births) rates (UNICEF 2017). There are also variations betweencountries and within the districts of countries. In the Sustainable DevelopmentGoals (SDG) 2018 progress report on SDG 3 Ensure healthy lives and promotewell-being for all at all ages, the UN stated that, while the quality of global healthis increasing, “people are still suffering needlessly from preventable diseases,both infectious and non-communicable, “and too many are dying prematurely”(United Nations Economic and Social Council 2019).Promoting, and achieving, the World Health Organization (WHO) goals forbreastfeeding is essential for achieving SDG 3. The WHO recommends “mothersworldwide to exclusively breastfeed infants for the child’s first six months to achieveoptimal growth, development and health. Thereafter, they should be given nutritiouscomplementary foods and continue breastfeeding up to the age of two years orbeyond” (World Health Organization 2011). These recommendations are consistentwith the historical cultural practices of all societies, and the promotion of breastfeedingis a return to a pre-commercial era.Breastmilk provides complete nutrition for an infant, supporting optimalgrowth and development, for the first six months of life, and protects against somechildhood diseases and some chronic disease later in life (Horta and Victora 2013).Physiologically, almost all mothers can breastfeed, and sometimes grandmothersor relatives can re-lactate to feed an infant if a mother is prevented from doing soby illness. In some lower–middle income countries (LMICs), such as the Maldivesand Papua New Guinea, most all mothers initiate breastfeeding with rates ofalmost 100% (Binns 1976; Raheem et al. 2014). Some Scandinavian countries have31almost reached this level and, in Denmark, rates of initiation of 99% have beenreported (Maastrup et al. 2019). With the help of family, the health system and society,and a supportive environment, high rates of breastfeeding are possible for all mothers.There are, of course, a few situations where breastfeeding is not possible (WorldHealth Organization 2009). These situations include seriously ill, low birthweightinfants and some maternal and infant infections. Many of these infants benefit fromexpressed breastmilk, or the feeding of breastmilk can be commenced later.The aim of this review is to demonstrate the central role that the promotion ofbreastfeeding has to achieving the Sustainable Development Goals.2. Materials and MethodsThis review was based on a search of the English language literature usingthe keywords ‘breastfeeding’, ‘sustainability’ and ‘infant feeding guidelines’. TheWeb of Science, Science Direct and PubMed databases were used with no timerestrictions. All studies on the importance of breastfeeding are limited by the ethicalrestraints of undertaking research on infants in such a critical field (Binns et al. 2017).Most studies are, therefore, observational in nature, but the accumulation of evidenceover many studies reassures of the benefits of breastfeeding for infants, their mothersand society.3. Results: Sustainable Development Goal 3 Specific TargetsSpecific targets have been set within each of the Sustainable DevelopmentGoals, including specific health targets for SDG 3 (World Health Organization 2017).The promotion of breastfeeding will contribute to most of these targets, in conjunctionwith other health interventions.3.1. Reduce Global Maternal MortalityBy 2030, reduce the global maternal mortality ratio to less than 70 per 100,000live births (World Health Organization 2017).The global maternal mortality rate has fallen in recent years, from anestimated 451,000 maternal deaths in 2000 to 295,000 in 2017. The maternalmortality ratio is now 211 maternal deaths per 100,000 live births (World HealthOrganization 2019a). This is a continuing public health tragedy that means thatan estimated 808 mothers are dying in childbirth every day. The global lifetimerisk of maternal mortality for a 15-year-old girl in 2017 was estimated at 1 in 190.During the period 2012–2017, almost 80% of live births worldwide occurred with theassistance of skilled health personnel, up from 62% in 2000 to 2005 (United Nations322019). Early initiation of breastfeeding, as advocated in the Baby Friendly HospitalInitiative, raises oxytocin levels after delivery, causing the contraction of the uterus,and may reduce post-partum hemorrhage (Sentilhes et al. 2016; WHO UNICEF 2018).This would have a particular benefit in LMICs of reducing post-partum hemorrhage,which continues to be an important cause of maternal deaths, particularly wheredeliveries occur away from well-equipped facilities.3.2. Reduce Neonatal MortalityBy 2030, end preventable deaths of newborns and children under 5 years of age,with all countries aiming to reduce neonatal mortality to at least as low as 12 per1000 live births and under-5 mortality to at least as low as 25 per 1000 live births(World Health Organization 2017).The Global Burden of Disease (GBD) project found that 6.64 million deaths ofchildren and adolescents occurred in 2017 (GBD 2019). In 2018, worldwide, 5.3 million,85% of deaths among children, occurred in the first five years of life and 2.5 million(47%) in the first month of life (UNICEF 2019b). While this is a reduction on previousdecades, it is still a huge public health burden. Infectious diseases remain the leadingcause of preventable deaths for children under the age of 5 years. Lower respiratorytract infections (15%), diarrheal diseases (8%) and malaria (5%) are the leading causesof death globally among children under the age of 5 (UNICEF 2019b; Walker etal. 2013). Infants and children with undernutrition are particularly vulnerable toinfections, and nutrition-related factors contribute to about 45% of deaths in childrenunder 5 years of age (UNICEF 2019b).In the original WHO monograph on nutrition and infection by Scrimshaw et al.,the authors described the importance of breastfeeding on infant survival: “the fate ofnewborn infants in many pre-industrial areas seems to depend largely on whetherthey are breastfed or not - either they are nursed or they die” (Scrimshaw et al. 1968).The importance of exclusive breastfeeding for six months to reduce infant mortalitywas demonstrated in the classic WHO Collaborative Study, which demonstratedhigher odds, as high as 6.0, of death before six months of age for infants who werenot breastfed (WHO Collaborative Group 2000). In a review at the beginning ofthe millennium for UNICEF, exclusive breastfeeding during the first 6 months oflife was found to have the single largest potential impact on child mortality of anypreventive intervention (Jones et al. 2003). In this review, Level One evidence foundthat exclusive breastfeeding prevented infant deaths from diarrheal disease, lowerrespiratory tract disease and neonatal sepsis (Jones et al. 2003). In the PROBITstudy, a postnatal breastfeeding intervention increased breastfeeding rates and33reduced gastro-intestinal infections in infants (Kramer et al. 2001). Numerousstudies and reviews have demonstrated the reduction in infectious diseases andhospital admissions of infants who are breastfed in countries at all levels of economicdevelopment (Horta and Victora 2013; Nguyen et al. 2020; U.S. Department of Healthand Human Services 2011). The GBD study noted the importance of sudden infantdeath syndrome (SIDS), a condition for which exclusive breastfeeding offers someprotection. A pooled data analysis of SIDS and breastfeeding found a reductionof 50% for infants breastfed for more than two months (Thompson et al. 2017).Breastfeeding, according to the WHO recommendations, will result in a majorreduction in the number of deaths under the age of 12 months by at least 820,000 eachyear (Rollins et al. 2016). It is also estimated that up to 50% of neonatal infant deathscould be averted if breastfeeding is initiated within the first hour of birth (Khan et al.2015). In LMICs, an estimated 13% of all child deaths could be prevented if optimalbreastfeeding levels are achieved (Nkoka et al. 2019).The mechanism for the effectiveness of breastmilk in protecting againstinfections includes the composition of breastmilk with antibodies, non-specificimmune factors and cellular components. An important mechanism for theprevention of infectious disease is the establishment of the microbiome. Breastmilkcontains prebiotics and probiotics, and exclusive breastfeeding results in a ‘healthy’microbiome. The microbiome of exclusively breastfed infants contains a higherproportion of Bifidobacteria and Lactobacillus spp., compared to formula-fed infants.These species are protective against gastrointestinal infections (Dong and Gupta2019). The hormonal changes of breastfeeding contribute to the beneficial effects ofbreastfeeding on ovarian and breast cancers, and to birth spacing (Binns et al. 2016;Smith and Harvey 2011).Additionally, breastfeeding reduces the risk of mortality in children under 5 yearsof age through its effect on birth spacing. Breastfeeding exerts a natural contraceptiveeffect by suppressing ovulation and delaying the return of menstruation, leading toincreased birth spacing and fewer children (Sundhagen 2009). The risk of stunting,anemia, and mortality is higher among the children born to women with a highernumber of births and short birth intervals.Achievement of the SDG 3.2 target would require an annual reduction ofapproximately 1.5 million deaths of children under 12 months of age. At least 50% ofthis target could be realized by feeding infants according to the WHO Guidelines(Victora et al. 2016).343.3. End Specified EpidemicsBy 2030, end the epidemics of aids, tuberculosis, malaria and neglectedtropical diseases and combat hepatitis, water-borne diseases and othercommunicable diseases (World Health Organization 2017).Breastfeeding offers some protection against diarrheal diseases, reducing therates by approximately 65% (U.S. Department of Health and Human Services 2011).It is not known if breastfeeding provides any protection against AIDS, malaria andtuberculosis, but partial protection is insufficient, and other public health measuresare required. The WHO recommends that mothers known to be HIV-infectedshould be provided with lifelong antiretroviral therapy or antiretroviral prophylaxisinterventions to reduce HIV transmission through breastfeeding. Mothers knownto be HIV-infected (and whose infants are HIV-uninfected or of unknown HIVstatus) should exclusively breastfeed their infants for the first six months of life,introducing appropriate complementary foods thereafter, and then continuing tobreastfeed (similar to the general population) (World Health Organization 2019b).Partial breastfeeding in the first six months of life provides inadequate protectionagainst the vertical transmission of HIV from mother to child (Coutsoudis and Rollins2003). Climate change will increase the global geographic spread and the incidence ofmany infectious diseases (Ahdoot et al. 2015; Philipsborn and Chan 2018). In infantsand children, breastfeeding is important in protecting against infections, and makingpopulations more resilient to such changes in the longer term (Lee and Binns 2019).3.4. Reduce Premature Mortality from Non-Communicable DiseasesBy 2030, reduce by one third premature mortality from non-communicable diseasesthrough prevention and treatment, and promote mental health and well-being(World Health Organization 2017).Improving breastfeeding rates has a role in the long-term prevention ofnon-communicable diseases. Within the time frame of the SDGs, breastfeedingcan reduce the rates of some non-communicable diseases (NCDs) in mothers, and,generally, the effect is proportional to the total amount of time spent breastfeeding.Breastfeeding reduces the rates of ovarian cancer, premenopausal breast cancer andType II diabetes (Gunderson et al. 2015; Scoccianti et al. 2015; Shield et al. 2018;Su et al. 2013; Victora et al. 2016; Zhang et al. 2004). A review of six cohort studieswith 273,961 mothers found that the relative risk of developing diabetes for thehighest duration of breastfeeding versus the lowest was 0.68 (95% CI = 0.57–0.82),reflecting a strong association between breastfeeding duration and lower rates of35diabetes (Aune et al. 2014). Mothers who have breastfed may lose weight morerapidly after pregnancy and are less likely to be obese (Snyder et al. 2019). In along-term follow up of overweight mothers, those who exclusively breastfed forfour or more months and continued breastfeeding for 12 or more months were onaverage 8 kg lighter six years later compared to mothers who had not breastfedtheir infants (Sharma et al. 2014; Tahir et al. 2019). Breastfeeding reduces the riskof subsequent cardiovascular disease in mothers, by about 10% (Nguyen et al.2017; Peters et al. 2017). The Women’s Health Initiative Study (n = 139 681) foundthat a lifetime history of more than 12 months lactation resulted in a reduction ofhypertension (OR = 0.88), diabetes (OR = 0.80), hyperlipidemia (Or = 0.81) andcardiovascular disease (OR = 0.91) (Schwarz et al. 2009). A follow-up of the EuropeanInvestigation into Cancer and Nutrition prospective cohort (n = 322,972) found thatmothers who had breastfed an infant had a reduced risk of dying over the followingdecade (OR = 0.92) (Merritt et al. 2015). The rate of perinatal depression is lower inmothers who continue breastfeeding (Xu et al. 2014; Yusuff et al. 2015).The roots of non-communicable diseases lie in early life nutrition. The promotionof breastfeeding to meet the WHO guidance and appropriate nutrition during thefirst 1000 days of existence will result in a reduction in chronic disease later in life.Infants who are breastfed have lower rates of obesity. Other chronic diseases that arereduced by breastfeeding include diabetes (both type 1 and type 2), hypertension,cardiovascular disease, hyperlipidemia, some types of cancer and inflammatorybowel disease and related digestive system disorders (Ananthakrishnan et al. 2018;Binns et al. 2016).The role of the human microbiome in health and disease is being increasinglyrecognized. Breastfeeding has an important role in establishing a healthy microbiome,and this contributes to the reduced prevalence of chronic disease through thedevelopmental origins of health and disease process (Stiemsma and Michels 2018).3.5. Strengthen the Prevention and Treatment of Substance AbuseStrengthen the prevention and treatment of substance abuse, including narcoticdrug abuse and harmful use of alcohol (World Health Organization 2017).The use of alcohol, tobacco products and other drugs is contra-indicated duringbreastfeeding, and this advice is given in public health guidelines for infant feeding(Binns et al. 2018; National Health and Medical Research Council 2013).363.6. Halve Global Road Traffic Deaths and InjuriesBy 2020, halve the number of global deaths and injuries from road traffic accidents(World Health Organization 2017).Not applicable to breastfeeding.3.7. Universal Access to Sexual and Reproductive Health-Care ServicesBy 2030, ensure universal access to sexual and reproductive health-care services,including for family planning, information and education, and the integrationof reproductive health into national strategies and programmes (World HealthOrganization 2017).Appropriate birth spacing results in healthier mothers and improvedbreastfeeding outcomes. Teenage mothers are less likely to breastfeed and tohave a shorter duration of breastfeeding than older mothers (Kanhadilok et al. 2016).Postponing the age of reproduction until adulthood will improve the health ofmothers and infants, and this highlights the need to make sexual health servicesavailable to this age group.Temporary contraception for new mothers whose monthly bleeding has notreturned requires exclusive or full breastfeeding day and night of an infant lessthan 6 months old and may be 98–99% effective (Tucker et al. 2011; World HealthOrganization 2018a).3.8. Universal Health CoverageAchieve universal health coverage, including financial risk protection, access toquality essential health-care services and access to safe, effective, quality and affordableessential medicines and vaccines for all (World Health Organization 2017).Universal health care provides the opportunity for mothers and fathers to attendhealth services and obtain education needed before birth. After birth mothers needappropriate treatment and advice on the best ways to continue breastfeeding ifcomplications occur, such as mastitis. On the 30th anniversary of the Convention ofthe Rights of the Child the UNICEF Special Rapporteur on the Right to Food issued areport stating that support for breastfeeding, as implied in Article 18, is consistentwith the legal obligations most countries have committed to, by their ratification ofthe Convention, which includes obligations to protect children’s right to a healthyfood environment (United Nations Children’s Fund and United Nations SpecialRapporteur on the Right to Food 2018).37Breastfeeding will reduce the demand on health services as infants; childrenand adults are less likely to require health service treatment (see above). For mothers,breastfeeding reduces the rates of a significant number of diseases, reducing overalldemand and enabling expansion to unreached areas and releasing resources forpromoting and supporting breastfeeding.3.9. Reduce Death and Illness from Hazardous Chemicals, Pollution and ContaminationBy 2030, substantially reduce the number of deaths and illnesses from hazardouschemicals and air, water and soil pollution and contamination (World HealthOrganization 2017).Persistent organic pollutants (POPs) have been of environmental and healthconcern for more than half a century. The only two countries with long temporaltrend studies are Japan and Sweden. In most cases, the trends show decreasingconcentrations of POPs in mothers’ milk (Fang et al. 2015). Plastic infant feedingbottles have been shown to release bisphenol A and S into infant formula(Russo et al. 2018; Walker et al. 2011). Obviously, breastfeeding is the simplestway to avoid this problem.4. Breastfeeding and the Other SDGsThe Sustainable Development Goals are an integrated whole, and Goal 3 shouldbe considered along with the other 16 goals. Increasing breastfeeding is essential toachieving Goal 3 of the SDGs. Breastfeeding will also make a major contribution toachieving other goals:• SDG 1: No Poverty. There is a strong link between health and economicdevelopment. Gallardo-Albarran has examined progress in the 20th centuryand demonstrated that improving health has contributed to a narrowing of theincome gap between countries (Gallardo-Albarran 2018). In a large long-termcohort study, breastfeeding was associated with improved performance inintelligence tests three decades later, and there was an association betweenbreastfeeding and increased educational attainment and income in adulthood(Victora et al. 2015).• SDG 2: Zero Hunger. Breastmilk, while providing the optimal source of nutritionfor infants, and substantial benefits for mother, is also substantially cheaperthan the available alternative, which is commercial infant formula. Breastmilkrepresents a valuable lost ‘natural’ resource when replaced with formula. It wasestimated that, in 2012, the total potential value of breastmilk in the USA was 11038billion USD, but 2/3 of this is lost due to sub-optimal breastfeeding (Smith 2013).The total world milk formula sales grew by 40.8% from 5.5 to 7.8kg/infant/childin the period 2008–2013, and is projected to grow at the rate of 9% per annumover the next decade (Allied Market Research 2017; Baker et al. 2016).• SDG 4: Education. There is increasing evidence that breastfeeding also conferslong-term benefits to the infant, not only in health and disease, but also in thedevelopment of human capabilities (Horta 2019; Strom et al. 2019). Childrenwho have been breastfed will have, on average, a slightly higher IQ and behealthier, including being less likely to be obese. These factors will improveeducation performance.• SDG 5: End Discrimination against Women. Promoting breastfeeding shouldprevent 20,000 deaths of mothers from breast cancer annually (Aryeetey et al.2018; Victora et al. 2016). As part of the strategies to enable breastfeeding,the provision of paid parental leave should be expanded (Heymann et al. 2017).Mothers are often unable to continue breastfeeding their infants after theirreturn to work, but there are many strategies to make this easier for them(Lakati et al. 2002).• SDG 8: Decent Work and Economic Growth. Breastfed infants had improvedcognitive development (higher IQ), and this appears to be dose-related. They arealso healthier, and the advantage of better health persists into adulthood.When they reach adulthood, a large cohort study documented higher incomesin breastfed infants (Straub et al. 2016; Victora et al. 2015). In situations wheninfants are fed formula, the cost and time spent in preparation impose significantburdens on a family (Siregar et al. 2018; Smith 2019; Walters et al. 2019).• SDG 9: Reduced Inequality. The breastfeeding of all infants will assist in reducinginequality. Where artificial infant formula is promoted and available, poorerfamilies may purchase cheaper varieties, over dilute the formula to reduce costsor use contaminated water supplies. In recent years, there have been instancesof contamination of infant formula and shortages of supplies (Qiu et al. 2010;Xin and Stone 2008). It is difficult (but not impossible) for mothers to resumebreastfeeding, and in the case of the Chinese contamination, parents spent largeamounts of money buying formula that had been imported from high incomecountries. Food security for infants and young children is not possible withouthigh rates of breastfeeding (Salmon 2015).• SDG 12: Responsible Consumption and Production. The alternative to breastmilkis the use of infant formula, which is usually based on dairy milk production.The carbon footprint of milk production is high and manufacture into infant39formula requires large quantities of potable water in the order of 4000 L of waterfor one kg of formula milk powder (Clune et al. 2017; Hagemann et al. 2011;Karlsson et al. 2019; Rollins et al. 2016). If access to pure water is difficult, and itmay become more difficult with climate change, using formula can be verydangerous. The cost of less than optimal breastfeeding is substantial, due to theincrease in child and maternal morbidity and mortality (Bartick and Reinhold2010; Bartick et al. 2013). The loss of productivity due to the lower level ofcognitive development in infants who are not breastfed is estimated at 302 billionUSD annually, or 0.49% of world gross national income (Rollins et al. 2016).5. Disaster Management and BreastfeedingThe 17 Sustainable Development Goals (SDGs) include 169 targets used tomonitor achievements. The United Nations Office for Disaster Risk Reduction(UNISDR) has identified 25 targets related to disaster risk reduction in 10 of the17 SDGs (United Nations Office for Disaster Risk Reduction 2015). Unfortunately,with the effects of climate change becoming more prominent, the number andseverity of natural disasters is increasing. It is important that, in any disastersituation requiring the provision of food, the breastfeeding of infants and youngchildren receives early attention. If it is at all possible for mothers to continue tobreastfeed, they should be encouraged as much as possible, in order to minimizeinfant morbidity. The provision of emergency supplies of infant formula in disastersituations should be carefully managed to avoid permanent changes to infantfeeding patterns. Only high-quality infant formula in plain packaging should beused to avoid advertising and breaching the International Code of Marketing ofBreast-Milk Substitutes (the ‘BMS Code’) (WHO 1981; World Health Organization2018b). The promotion of breastfeeding and feeding mothers (water and food) willbe more sustainable and provide better health outcomes than distributing infantformula (Binns et al. 2012b; Summers and Bilukha 2018).6. Achieving Breastfeeding GoalsIn historical times, breastfeeding was universal, as all infants were breastfedby their mothers or a wet nurse. Currently, the WHO/UNICEF estimates thatworldwide, 44% of infants begin breastfeeding within one hour of birth (UNICEF2019a). Exclusive breastfeeding 0–6 months is estimated at 42%, and 65% continuebeyond 12 months, but these results are dependent on the method and definitionsused in collecting the data (Binns et al. 2012a). Improving breastfeeding rates isone of the most important steps in achieving the targets of SDG 3 (Perez-Escamilla402017). The Sustainable Development Goals provide an appropriate framework forsupporting universal breastfeeding targets. The WHO and UNICEF have endorsedmany strategies to improve breastfeeding that have been evaluated. However,the resources and the will to implement have not been forthcoming. In part, this isdue to the long-term nature of public health benefits compared to the short-termpolitical cycle, and, in part, due to the role of industry in infant formula production andpromotion. Strategies to achieve optimum breastfeeding will require the involvementof family, health services, local and national governments and society in general.A global environment supportive of breastfeeding is required, which would includethe following components.6.1. A Supportive Societal EnvironmentMedia reports, advertising and social media ideally should all portray thebenefits and joys of breastfeeding, as has already being done by many mothers’groups and breastfeeding advocates. Breastfeeding needs to be regarded as the normand specific programs of information need to be implemented to provide accurateinformation. While breastfeeding is an individual activity, it requires investment ata societal level (Brown 2017). In a globally connected world, countries which arelarge producers of infant formula have a duty to limit their exports of these products(Galtry 2013; Gribble and Smith 2014). Public places need facilities where mothers cancare for their infants and feel comfortable about breastfeeding. In many economies,mothers undertake paid employment and would like to continue breastfeeding whilereturning to work. Maternal leave, including paid leave, has been shown to improvebreastfeeding rates (Chai et al. 2018). Informal arrangements to breastfeed and returnto employment are also beneficial (Lakati et al. 2002).6.2. Maternal and Family Preparation for BreastfeedingGiving mothers knowledge and motivation about breastfeeding is important.The best time to begin to discuss the benefits of breastfeeding is before or soonafter the mother becomes pregnant (National Health and Medical Research Council2012). Antenatal education, counselling and encouragement are important, and areof benefit. This can be achieved through formal structures, the use of volunteer healthpromotors or village health workers. Fathers and other close family members areimportant participants in infant care, and they all need knowledge and motivation(Maycock et al. 2013). The use of smartphones has become almost universal and theyprovide an important medium for sharing knowledge and experience, provided thatthis is moderated to ensure accuracy (White et al. 2019).416.3. Health Service SupportUniversal health access will mean that all health workers will need educationinto the benefits of breastmilk and the BMS Marketing Code so that BFHI principlescan be implemented at all levels of the health service. Breastfeeding counsellingand promotion during antenatal education is important. A Cochrane review onprenatal intervention found that healthcare-professional-led breastfeeding education,and non-healthcare-professional-led counselling and peer support interventionscan result in some improvements in the number of women beginning to breastfeed(Balogun et al. 2016; Perez-Escamilla 2020). The Baby Friendly Hospital (and healthservice) Initiative needs to be implemented universally to provide a favorableenvironment for mothers and infants (Perez-Escamilla 2020; Spaeth et al. 2018;WHO 2019; WHO UNICEF 2018). At present, the endorsement or even accreditationof BFHI is widespread, but may not always be applied in practice (Hawkins et al.2014; WHO UNICEF 2018). The aims of the BFHI include the early initiation ofbreastfeeding (early skin to skin contact), feeding colostrum and continued exclusivebreastfeeding, all of which are highly effective and low-cost interventions for shortand long term health of infants (Bhutta and Labbok 2011; Bhutta et al. 2014; Rollinsand Doherty 2019; Rollins et al. 2016). Hospitals and other components of the healthsystem must not promote infant formula in any way, or accept free or low-costsupplies or promotional material.6.4. The Promotion of Breast Milk SubstitutesRecognizing the damage caused by breast milk substitutes, the World HealthAssembly approved the International Code of Marketing of Breast-Milk Substitutesin 1981(WHO 2020a). Support, in principle, for the code is extensive, but, when itcomes to legislative action, it is often limited (WHO and UNICEF 2020). Very fewcountries have marketing restrictions on products suitable for up to three years of age,and the majority have voluntary restrictions only up to six months of age (WHO 2020a,2020b). The Code is widely breached in many LMICs, with widespread advertisingacross all media, including television, print and social media (IBFAN 2018). Infantformula products designed for toddlers are widely marketed, and parents oftenassume that the exaggerations in the advertisements apply to infants of all ages.Many countries, particularly middle-income countries, have experienced a surge ininfant formula use, as incomes increase (Neves et al. 2020; Son 2017). Vietnam isan example of an LMIC that has experienced sales growth of 12% per annum overthe past decade (Whitehead 2020). The government’s response has been similarto other Asian countries such as China and Japan, to encourage and support local42production of infant formula. This is despite cow milk production for infant formulahaving a large carbon footprint and requiring large quantities of potable water in itsproduction (Smith 2019; Sultana et al. 2014). The use of plain label packaging hasbeen highly successful in reducing tobacco sales, and could be beneficial in curbingthe widespread promotion of infant formula (Drovandi et al. 2019; Wise 2017).6.5. Specific Groups May Need Special Programs eg Obese Mothers, IllnessThere are a small number of mothers for whom breastfeeding may becontra-indicated (World Health Organization 2009). These mothers and othermother–infant dyads in which there are physical conditions (e.g., obesity), or illnessesthat impair breastfeeding, may require special counselling and support from thehealth system. Breastfeeding can usually be maintained using the mother’s ownsupply or from donor breastmilk.6.6. The COVID-19 PandemicThere have been reports that mothers with COVID have stopped breastfeedingtheir infants, and this action is being recommended in some countries, includingJapan. However, the World Health Organisation recommends: “that mothers withsuspected or confirmed COVID-19 should be encouraged to initiate or continue tobreastfeed (World Health Organization 2020). Mothers should be counselled that thebenefits of breastfeeding substantially outweigh the potential risks for transmission”.This is the position of most pediatric societies (Rozycki and Kotecha 2020).7. ConclusionsGlobally, appropriate breastfeeding practices have the potential to preventover 800,000 deaths of children under five years of age annually. In low incomecountries, an estimated 13% of all child deaths could be prevented if optimal levelsof breastfeeding were achieved. If breastfeeding increases, infants, children andadults will all be healthier, and contribute to achieving the SDGs. Minimizingavoidable health care costs will facilitate achieving universal health care. Promotingbreastfeeding will not have any detrimental on any of the other SDGs.The sustainability costs of breastmilk substitutes promoted by industry asalternatives to breastfeeding are massive, and from an economic perspective, the costof not breastfeeding is into the trillions of dollars. When we add the human costsof not breastfeeding, the benefits of promoting breastfeeding, as the world workstowards achieving the Sustainable Development Goals, are overwhelming. To achieve43these benefits, the combined efforts of many sectors of society and government willbe required.We summarize our chapter in the following statement:Breastmilk is best for all babies, mother–baby dyads, for lifetime health,for sustainability, and for the environment and economy. Protect it from harmor it is gone.Author Contributions: Each author made substantial contributions to the conception of thechapter, the acquisition, analysis, or interpretation of the literature references used in the work,and writing and revision. The final manuscript has been approved by all authors, and weagree to be personally accountable for the authors’ contributionsFunding: This research received no external funding.Conflicts of Interest: The authors declare no conflict of interest.ReferencesAhdoot, Samantha, Susan. E. Pacheco, and The Council on Environmental Health AmericanAcademy of Pediatrics. 2015. Global Climate Change and Children’s Health. Pediatrics136: E1468–E1484. [CrossRef] [PubMed]Allied Market Research. 2017. Baby Infant Formula Market Overview. Availableonline: https://www.alliedmarketresearch.com/baby-infant-formula-market (accessedon 5 October 2019).Ananthakrishnan, Ashwin N., Charles. N. Bernstein, Dimitros Iliopoulos, Andrew Macpherson,Markus. F. 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Does infant feeding method impact on maternal mentalhealth? Breastfeeding Medicine 9: 215–21. [CrossRef]Yusuff, Aza Sherin, Li Tang, Colin W. Binns, and Andy H. Lee. 2015. Prevalence and riskfactors for postnatal depression in Sabah, Malaysia: A cohort study. Women and Birth 28:25–29. [CrossRef]Zhang, Min, Xi Xie, Andy H. Lee, and Colin W Binns. 2004. Prolonged lactation reducesovarian cancer risk in Chinese women. European Journal of Cancer Prevention 13: 499–502.[CrossRef]© 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an openaccess article distributed under the terms and conditions of the Creative CommonsAttribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).53Taxation of Tobacco, Alcohol andSugar-Sweetened Beverages for Achievingthe Sustainable Development GoalsVioleta Vulovic and Frank J. Chaloupka1. IntroductionNCDs cause more than two-thirds of mortality in the world. More than 40 percentof these deaths are premature, and most of them are preventable. About 80 percentof NCD attributable premature deaths happen in low- and middle-income countries(LMICs). Moreover, low- and middle-income households bear 67 percent of NCDdisease burden (IHME 2019), and one third of these deaths affects the economicallyproductive age group, the age group below 70. Numerous studies show that tobaccouse, obesity, and diabetes, especially among lower socioeconomic groups, have beenhigh risk factors for NCDs (Niessen et al. 2018), and can lead to long-term economicconsequences for individuals, their families, and the society. Around 60 percent ofdeaths from HCDs are caused by cardiovascular and respiratory diseases and diabetes.The number of deaths from these diseases has increased globally by 21.7 percentbetween 2000 and 2015. In terms of their share in total NCDs, there has been a verymodest decline, from 61 percent in 2000 to 59 percent in 2015, primarily driven by adecline in high-income countries (HICs) (Figure 1). Potential economic implicationsof NCDs can be enormous if this trend continues, with an estimated cumulativeglobal output loss by 2030 of USD 47 trillion (Bloom et al. 2012).SDGs represent a global plan of action to end poverty, fight inequality, tackleclimate change, and ensure that people live in peace and prosperity by 2030 (UN2015b). Among its 17 goals, SDG target 3.4 under SGD 3 (good health and well-beingfor people) focuses on reducing premature mortality attributed to NCDs by one thirdby 2030. Progress on SDG target 3.4 is of a major relevance in accomplishing atleast five other SGDs, specifically, SDG 1 (reducing poverty), SDG 2 (zero hunger),SDG 4 (quality education), SDG 8 (decent work and economic growth), and SDG 10(reduced inequalities).NCDs tend to be disproportionally clustered in lower socioeconomic groups ofa society. While evidence on the relationship between the socioeconomic status andNCDs in HICs is extensive, there is little systematic evidence to support this link inLMICs. There are a few ways of how NCDs and poverty (SDG 1) are related. Firstly,55poverty is linked to limited access to health care, and to an unhealthy diet and use oftobacco, which are targeted under SDG 3 (The Lancet 2017). People living in povertyare less able to practice healthy living and are more predisposed to suffering fromchronic diseases (Wagstaff 2002).0% 010%520%1030%1540%2050%70% 2560%2000 2010Global2015 2000 2010Low incomecountries2015 2000 2010Lower-middle-income countries2015 2000 2010Upper-middle-income countries2015 2000 2010High-income countries2015Total number of deaths (millions) (RHS)Cardiovascular diseasesRespiratory diseasesDiabetesFigure 1. Deaths from selected NCDs by country-income group. Deaths causedby cardiovascular diseases, respiratory diseases, and diabetes total presented as %in total NCDs (LHS); total number of deaths from these three diseases presentedin millions (RHS). Source: Authors’ calculations using WHO (2018a).Good nutrition is estimated as a necessary determinant for reducing NCDs andmeeting most of SDGs (WHO 2017). Malnutrition at an early stage in life increasesthe risk of developing chronic diseases and hinders children’s cognitive developmentand growth (Fall et al. 2010; Boney et al. 2005). Moreover, low socioeconomic statusincreases one’s risk to develop chronic diseases and predisposes them and theirfamilies to economic hardship due to high out-of-pocket costs, lost earnings andemployment, and then impoverishment (Hanratty et al. 2007). In such situations,families can lose the ability to support opportunities for education and humandevelopment of their children, especially when they have to stay at home and providecare to ill family members (Engelgau et al. 2012). Even those who are insured canincur very high medical costs of treatment of NCDs when they have low incomeor limited coverage (Jan et al. 2018), and they are commonly not able to pay for it(Levesque et al. 2007).Better economic conditions and quality education enhance the health outcomesof household members, while low socioeconomic status leads to poor health, whichfurther reduces their income status and may lead to poverty (Nugent et al. 2018; Jan56et al. 2018). High premature mortality and morbidity from NCDs reduce workers’labor productivity and earnings and their family income (Bertram et al. 2018) andhinders a country’s economic growth and development (SDG 8). Without a reductionin NCD attributed mortality and an increase in economic growth, especially inLMICs, the world will see not only the continued but deepening inequality withinand between countries (SDG 10).Around 39 percent of 40 million NCD attributed deaths in 2015 was causedby tobacco use (8 million), heavy alcohol consumption (3 million), and obesity(4.5 million) (WHO 2018b, 2019c; Gakidou et al. 2017). One of the major causes ofobesity, globally, has been an increase in consumption of SSBs. Taxation is one ofthe most cost-effective measures that encourage healthy behavior, and prevent andreduce NCDs. By increasing prices, they can discourage consumption of tobacco,alcohol, and SSBs, and generate additional government revenues much needed fordevelopment spending (NCI and WHO 2016; Wagenaar et al. 2010; Sornpaisarnet al. 2013; Thow et al. 2018). However, despite their potential, these taxes havebeen frequently opposed and underused by the policymakers. Current tobacco taxcollection in most LMICs is still well below 1 percent of GDP, which does not comeeven close to covering the estimated healthcare costs associated with tobacco-relatedillnesses estimated at well above 1.8 percent of GDP (Goodchild et al. 2018).One of the most commonly used arguments by the policymakers for opposingtaxation of tobacco, alcohol, and SSBs is that they may be regressive. While theevidence from developing countries on the distributional impact of taxation oftobacco, alcohol, and SSBs is limited, the findings from available studies suggest thatthe concern about their harmful effect on the poor may be overstated and that, on thecontrary, they can result in health and welfare gains without imposing an excessiveburden on the poor (Sassi et al. 2018).This paper reviews existing evidence on adverse effects of consumption oftobacco, alcohol, and SSBs on health (SDG 3), and their relevance for achieving afew other related SDGs, including poverty reduction (SDG 1), nutrition (SDG 2),education (SDG 4), economic growth (SDG 8), and reduced inequality (SDG 10).Based on this evidence and evidence on the effectiveness of taxation in influencingconsumer behavior and in collecting additional much needed revenues, this paperalso builds a case for accelerating tax policy to meet development goals. The restof the paper is organized as follows. Section 2 reviews the evidence on the healthand development impacts of consumption of tobacco, alcohol, and SSBs. Section 3discusses the evidence on impact of tax and price policy on consumption of theseproducts and revenue impact of policy changes. Finally, Section 4 concludes the paper.572. Impact of Consumption of Tobacco, Alcohol and SSBs on Selected SDGs2.1. TobaccoThere is a significant body of research offering evidence on a negative impact oftobacco consumption on health and economic development. It has been estimatedthat tobacco causes more than 8 million deaths per year (WHO 2019c). Most of thosedeaths (7 million) are attributed to direct tobacco use, and more than 1 million to theexposure to second-hand tobacco smoke. Around 80 percent of these deaths happenin LMICs, and most of them are preventable. In terms of the regional disparity, almost60 percent of tobacco-attributable deaths happen in South-East Asia and WesternPacific regions (Figure 2). Around half of lifetime smokers die before reaching 70,while quitting before the age of 40 reduces the mortality risk by 90 percent (Jha et al.2015). Tobacco use significantly increases the risk of death from lung and othercancers, heart disease, stroke, respiratory disease, and tuberculosis (WHO 2019c).0%5%10%15%20%25%40%35%30%Eastern MediterraneanThe Americas Europe South-East AsiaWestern PacificAfricaFemale MaleFigure 2. Smoking-attributable deaths by gender and WHO region, 2016 (% intotal by gender). Source: Authors’ calculations using GBD 2015 Risk FactorsCollaborators (2016).The evidence on the impact of tobacco use on health outcomes in HICs hasbeen well documented, and it shows significant tobacco-related health disparities(TRHDs) among lower socioeconomic groups (Haustein 2006). This trend is in linewith disparities in cigarette consumption showing relatively higher consumptionby lower-income groups (Figure 3). Moreover, this disparity has been increasing, assmoking prevalence has declined relatively more among higher income groups thanamong those below the poverty line (NCI and WHO 2016). On the other hand, whilestill limited, the evidence from LMICs has been increasing, and showing a similar58trend for male smokers, as lower income men are significantly more likely to smokethan the higher income men (Efroymson et al. 2001). However, the picture is differentamong women. While in about two thirds of countries the poorest women aresignificantly more likely to smoke than the wealthiest women, in about one third ofcountries, mostly in Eastern Europe, the case is the opposite (Hosseinpoor et al. 2012).02004006008001.0001.6002.0001.8001.4001.200Poland Thailand Philipines Brazil EgyptUruguayLowest Middle High HighestLowFigure 3. Cigarette consumption by income group in selected countries in 2009.Measured by an average number of cigarette sticks per person. Source: Authors’calculations using CDC (2019).The economic impact of tobacco use can be very high. Evidence suggests thattotal global economic cost of smoking in 2012 was around 1.8 percent of global GDP(PPP$) (Figure 4), of which 25 percent were direct medical costs, and 75 percent indirectcosts due to morbidity and mortality (Goodchild et al. 2018). LMICs accounted foralmost 40 percent of this cost, while regionally, most of the cost (70 percent) was inthe Americas and Europe. A systematic review of studies from various countriesconducted between 1990 and 2011 finds that estimates vary greatly, depending on thescope, type of data, and methodology (NCI and WHO 2016). In LMICs, estimateddirect and indirect costs of tobacco use range from 0.1 percent of GDP in Lao PDR to3.4 percent of GDP in Philippines, while in HICs it is between 0.3 percent of GDPand 2 percent of GDP.593%2%1%0%Low-incomeLower-middle incomeUpper-middle incomeHigh incomeWestern PacificThe AmericasEastern MediterraneanEuropeAfricaSouth-East AfricaWorld (1,8%)1,2% 1,7% 1,1% 2,2% 0,6% 0,9% 1,0% 1,8% 2,4% 2,5%Figure 4. Economic costs of smoking by country-income group and WHO region,2012 (% of GDP). Source: Authors’ calculations using Goodchild et al. (2018).Through its adverse effect on physical health, tobacco use can significantlynegatively impact people’s financial health and socioeconomic status, even in thelong run. If a household’s principal earner is a smoker and develops a disease, thiswould lead to medical costs associated to a treatment of that illness, and possibly aloss of earnings due to disability, and even mortality. In 1998, in China, 30.5 millionpeople in urban areas, and 23.7 million people in rural areas were impoverished dueto direct tobacco spending and medical costs for treatment of tobacco-attributableillnesses (Liu et al. 2006). As workers from poorer households commonly have lowerlevel of education and lower skills, and usually work in labor intensive jobs, theirdisability often results in a relatively greater loss of earnings than with people withhigher income and more resources.Tobacco use can contribute to or exacerbate both primary and secondary poverty(NCI and WHO 2016; John et al. 2011). Primary poverty is defined as a situationin which an individual has no sufficient resources to afford necessities of life, whilesecondary poverty refers to a situation in which these resources are sufficient, but arenot used effectively (Liu et al. 2006). There are two main tobacco-associated factorscontributing to the impoverishment, the opportunity cost of tobacco use, and theburden due to illness, disability, and mortality.With limited resources, spending on tobacco products requires a trade-off inconsumption and crowds out basic necessities—food and non-food items (clothing,housing, education, healthcare, fuel). In India, spending on tobacco reduces spendingon food, education, and entertainment (John 2008). In Bangladesh, it crowds outspending on education and healthcare (Do and Bautista 2015), while in SouthAfrica, low income households sacrifise spending on dairy, fruits, nuts, and oils60due to spending on tobacco (Chelwa and Koch 2019). In other words, this foregoneconsumption of basic necessities is called the opportunity cost of tobacco use. Tobaccouse can hamper the standards of living of all income groups, but relatively more withpoorer than with richer households (Pu et al. 2008). These changes in the household’sinternal resource allocation could lead to a poor diet and malnutrition in children,poor health, and decreased opportunities to obtain education and gain skills (Sembaet al. 2007; Paraje and Araya 2018; Virk-Baker et al. 2019).Moreover, numerous studies provide evidence on the wage-gap between smokersand non-smokers (Hotchkiss and Pitts 2013; Bondzie 2016). The estimated gap rangesfrom as little as 1.5–3.5 percent to more than 20 percent, depending on which factorsthat may contribute to lower earnings have been accounted for, in addition to tobaccouse (Leigh and Berger 1989; Hotchkiss and Pitts 2013). In an attempt to explain thewage-gap due to tobacco use, studies have tried to evaluate the underlying causes,and have identified different reasons, from deteriorated health to lower productivity.In addition, it has been found that smokers place a higher emphasis on gratificationin the present over their future well-being, and therefore tend to make relativelylower investments in education and a healthy life-style than non-smokers.Economic costs from lost productivity resulting from presenteeism, absenteeismfrom work, and premature death of employees due to tobacco-related illnessescan be substantial, and consist of lost earnings for employees and lost revenuesfor the employers. Most of the available evidence comes from the HICs. It hasbeen estimated that smokers are absent from work 6.6 more days per year thannon-smokers in the US (Bunn et al. 2006) and 2.7 more days in the UK (Weng et al.2013). In terms of lost productivity, the estimated cost of smokers in the US is around$US 151 billion (0.9 percent of GDP) and around $US 6 billion (0.03 percent of GDP)for non-smokers due to second-hand smoke (SHS) exposure (USDHHS 2014), and inAustralia around $AU 8 billion (or 0.9 percent of GDP) (Collins and Lapsley 2008).Moreover, the cost of presenteeism represents more than 50 percent of total lostproductivity attributed to tobacco use in the US (Bunn et al. 2006). Evidence from theUS, European Union, China and Japan shows that around four years post-cessation,recent quitters report already higher work productivity than current smokers (Bakeret al. 2017; Suwa et al. 2017).In a long term, due to insufficient resources to meet basic needs caused bytobacco use and burden due to tobacco-attributed illnesses, mortality, and morbidity,and resulting poor nutrition and health, and poorer education and skills, a householdcan end up in a poverty trap (Haustein 2006; Liu et al. 2006), which may impair acountry’s welfare and economic development, and would widen social inequality.612.2. AlcoholThere is an extensive body of research on the health risks of alcohol consumption.The relevance of alcohol consumption to health and global development is reflectedin its inclusion within the SDGs. Specifically, SDG 3.5 focuses on strengtheningprevention and treatment of substance abuse, including harmful use of alcohol.Harmful use of alcohol contributed to 3 million deaths globally (WHO 2018b),which was about 39 deaths per 100,000 people (Figure 3), or 5.3 percent of all globaldeaths in 2016 (Figure 5). There is a significant variation in number and percentageof alcohol-attributable deaths by country-income group and WHO region. In 2016,the burden of deaths was the highest in lower-middle income countries (46.2 deathsper 100,000 people) and low-income countries (42.1 deaths per 100,000 people)and, regionally, in Africa (70.6 deaths per 100,000 people) and Europe (62.8 deathsper 100,000 people) (Figure 6). While there is no safe level of tobacco use, harmcaused by alcohol use depends on the volume and patterns of drinking. In 2010,alcohol-attributable cancer contributed to 4.2 percent of all cancer deaths (Parry et al.2011). It has also been shown that alcohol increases the risk of coronary heart diseaseand stroke (Corrao et al. 2004), and inadequate nutrition and obesity (Traversy andChaput 2015).As in case of tobacco, economic costs of alcohol use can be very high, and rangesubstantially between countries. Global evidence, which, until recently, has mostlybeen from HICs, on estimated economic burden of alcohol misuse ranges from 0.45to 5.44 percent of GDP (Thavorncharoensap et al. 2009). In the US, the estimatedeconomic cost of excessive drinking in 2006 was US$ 223.5 billion (1.7 percent ofGDP), of which 72.2 percent was from lost productivity and 11.0 percent fromhealthcare costs (Bouchery et al. 2011). Similar, the estimated cost in the EU in 2003was 1.2 percent of GDP (Anderson and Baumberg 2006), and in the UK in 2009 was1.4 percent of GDP (HM Government 2012). In Sri Lanka, it was estimated that theeconomic cost of alcohol-related illnesses in 2015 was US$ 885.9 million, or 1.1 percentof GDP (Ranaweera et al. 2018). A more comprehensive study conducted in SouthAfrica included both tangible and intangible costs, and estimated total economic costof harmful use of alcohol in 2009 at 10–12 percent of GDP (WHO 2014).620%2%4%6%8%10%12%Western Pacific South-East AsiaAfrica The Americas EuropeEastern MediterraneanWorld (5,3%)0,7% 4,1% 4,6% 5,1% 5,5% 10,1%Figure 5. Alcohol-attributable deaths (% of all deaths) in 2016 by WHO region.Source: Authors’ calculations using WHO (2019b).80%70%50%40%20%10%60%30%0%Lower-incomeLower-middle incomeUpper-middle incomeHigh incomeEastern MediterraneanWestern PacificThe AmericasSouth-East AfricaEuropeAfricaWorld (38,8%)42,1% 46,2% 39,5% 27,1% 7,0% 24,3% 34,1% 36,8% 62,8% 70,6%Figure 6. Alcohol-attributable deaths per 100,000 people (age-standardized) in 2016,by country-income group and WHO region. Source: Authors’ calculations usingWHO (2018b).Alcohol consumption has multiple social and economic impacts. Firstly, harmfulalcohol use and poverty are connected in many ways, as alcohol use can be both aresponse to, and a driver of, poverty. The risk of poverty is not related only to directspending on purchase of alcohol, but also the medical cost for treatment of relatedillnesses and lost earnings due to disability and mortality. Evidence shows thatdisadvantaged socioeconomic groups are more likely to bear heavier alcohol-relatedburdens than the higher income groups with the same level of consumption (Smithand Foster 2014). In LMICs, as in case of tobacco, alcohol use tends to crowd outspending on basic necessities, such as healthy food, education, and healthcare. InSri Lanka, the poorest users of alcohol and tobacco spend more than 40 percent oftheir income on these items (De Silva et al. 2011). In Madagascar, alcohol consuminghouseholds spent 14.1 percent of average monthly income on alcohol in 2010, with6333.6 percent of these households declaring that they had never been able to save(Tsikomia and Şarpe 2012). Even in countries with relatively low spending on alcoholand tobacco, such as Taiwan, the crowding out effect can be damaging to the lowestincome households (Pu et al. 2008).In many vulnerable socioeconomic groups, children bear a disproportionateburden of household’s alcohol consumption. With limited resources, spending onalcohol crowds out spending on food and education, depriving children of nutrientsand their right to primary education, both necessary for living a productive life.Moreover, heavy alcohol use among youth has been found to diminish chancesof completing a degree, especially among male youth from lower socioeconomicbackground (Staff et al. 2008), and chances of being employed after college graduationand of securing employment (Bamberger et al. 2018).Work problems associated with alcohol use are very relevant in many marketeconomies due to their high costs of alcohol-related productivity losses and otherwork problems (Rehm and Rossow 2001). The relationship between alcohol use andearnings has received significant attention in the literature, especially in HICs. Theempirical evidence on the impact of alcohol abuse on earnings is inconclusive. Whilesome earlier studies suggested that moderate drinking may even be beneficial forwork performance (Baum-Baicker 1985), but that the wage premium may declineas alcohol use increases (Berger and Leigh 1988), some more recent studies offera slightly different insight. A study from Canada found that heavy alcohol usershave lower earnings and lower returns to higher education relative to moderateor abstinent users (Hamilton and Hamilton 1997). Similarly, in the US, evidencesuggests that alcoholism leads to lower earnings, but more due to reduced numberof work hours that to a reduction in hourly wage (Renna 2008).2.3. Sugar-Sweetened BeveragesObesity is a form of malnutrition and represents a significant risk to publichealth and economic development. In 2016, 39 percent of world’s adult population(18 years and above) were overweight and 13 percent were obese, which was anincrease from 2000, with 30.8 and 8.7 percent, respectively (Figure 7). In recent years,the increases have been happening among children and young adults as well. In2016, around 41 million children under the age of 5, and 340 million children andadolescents aged 5–19, were either overweight or obese. Global trends show a positiverelationship between wealth and obesity (Low et al. 2009; Misra and Khurana 2008),as almost 60 percent of population in upper-middle-income and more than 80 percentin high-income countries were either overweight or obese in 2016. However, lower64income countries have been catching up, as they have been experiencing a muchhigher increase than higher income countries, with more than 50 percent growth inoverweight and obesity from 2000 to 2016 (Figure 7). While HICs do have a relativelyhigher obesity problem than LMICs, with economic development in LMICs, such asin China and India, obesity develops as well (James 2008). Almost half of overweightand obese children under the age of 5 now live in Asia, and the number has increasedby almost 50 percent in Africa since 2000.0%10%20%30%40%50%90%80%70%60%Overweight ObesityWorld2000 2016Low income2000 2016Lower-middle-income2000 2016Upper-middle-income2000 2016High-income2000 2016Figure 7. Prevalence of overweight and obesity among adults (18+ years of age)by country-income group, 2000 and 2016 (%). Source: Authors’ calculations usingWHO (2019a).In 2016, 4.5 million deaths worldwide was attributed to obesity, in comparisonto 3.5 million in 2006 (Gakidou et al. 2017). Diabetes caused 1.6 million deaths in 2015,which was 65.6 percent more than in 2000 (Figure 8). The increase has been muchmore rapid in LMICs than in HICs, and, by region, in Africa, Eastern Mediterranean,and South-East Asia.65120%100%80%40%20%60%0%Lower-incomeLower-middle incomeUpper-middle incomeHigh incomeEuropeThe AmericasWestern PacificAfticaEastern MediterraneanSouth-East Africa72% 100% 61,3% 16,8% 21,0%World (65,6%)42,5% 57,9% 74,1% 77,3% 108,7%Figure 8. Percent increase in diabetes attributed mortality between 2000 and 2015,by country-income group and WHO region. Source: Authors’ calculations usingWHO (2018a).Overweight and obesity are among the main contributors to poor healthcondition, as they may increase the risk of a large number of health problems, eitherindependently or in association with other diseases (Kopelman 2007). Overweightand obese children are more likely to develop serious health problems, includingtype-2 diabetes and high blood pressure, but also the psychological disorders. Addedsugar intake has been associated with multiple health risks, both among childrenand adults (Bovi et al. 2017). SSBs, in particular, are known to have a very high sugarcontent, and have been highly associated with overweight and obesity (Malik et al.2006) and high blood pressure (Malik et al. 2014). The same amount of sugar andcalories consumed in solid foods results in a significantly lower overall calorie intakethan when consumed as liquids, because calories are less satiating in a liquid form(Mourao et al. 2007).The economic costs attributed to obesity can be substantial and will onlyincrease if the current trend continues. The global economic cost from obesity hasbeen estimated at USD 2 trillion per year, which accounts for 1.5 percent of the 2018global GDP (PPP$) (Dobbs et al. 2014). As the evidence from LMICs is still emerging,most evidence on economic costs of obesity is from the HICs. In the US, the directmedical cost of treatment of severe obesity-related illnesses in 2014 was estimatedat US$ 69 billion (Wang et al. 2015), while the estimated cost of lost productivitydue to absenteeism in 2012 was US$ 8.65 billion (Andreyeva et al. 2014). Whenconverted to 2014 prices, these two costs together reached around 0.5 percent ofnational GDP. The evidence from Germany suggests significantly lower estimatedeconomic costs of EUR 12.2 million in 2008 (Lehnert et al. 2015). A corresponding66estimate for Thailand in 2009 was US$ 725.3 million, which accounted to 0.3 percentof its GDP (Pitayatienanan et al. 2014). Recent study estimated that, if current trendsin overweight and obesity continue, around 92 million lives will be lost in OECDcountries by 2050, and GDP will decline by 3.3 percent, on average (OECD 2019).Different socioeconomic groups are differently impacted in HICs and LMICsby consumption of SSBs. A comparison of a relationship between obesity, economicdevelopment and socioeconomic status, including income and education level,in 67 countries, has produced some useful insights (Pampel et al. 2012). Whileobesity problem increases with a country’s economic development, in HICs, highersocioeconomic groups are less likely to be obese, while in LMICs, those with higherincome and education level are more likely to be obese. The authors highlight that thistrend has a very relevant development implication. While economic developmentof a country is associated with an improvement in health condition of its citizens, itdoes not mitigate the problem of poor nutrition, as with development malnutrition isreplaced by obesity. At the same time, some countries, such as India, with economicdevelopment struggle with both malnutrition and obesity (Ravishankar 2012).3. Taxation of Tobacco, Alcohol and SSBs and SDGsThere is a very convincing body of evidence from various countries thatsubstantially increasing prices of tobacco through taxation is the single mosteffective way to reduce tobacco use and alcohol consumption (NCI and WHO2016; Anderson et al. 2009). Evidence on SSBs is still emerging and suggests thatincreased prices through sugar taxes are, similarly, an effective fiscal tool to promotehealth (Guerrero-López et al. 2017). Moreover, taxes on these three groups of productsare also an effective policy measure for domestic revenue mobilization and meetingSDGs. However, despite their potential to mitigate the risk factors of consumptionof tobacco, alcohol, and SSBs to health and NCDs, taxes on these products areunderutilized by policymakers.The economic justification for taxation of tobacco, alcohol, and SSBs is based onthe principle of correcting negative externalities (Pigou 1920) by imposing a tax ona good, which would result in a reduction of consumption and increase in welfare.Moreover, imposing a tax corrects for the information failure in markets of theseproducts, as consumers are misinformed about the full health consequences of theirconsumption (Chaloupka and Powell 2019). These costs, which consumers imposeon themselves but do not correctly internalize, are called “internalities”, and areused to make a distinction in the rationale behind “sin taxes” (Herrnstein et al. 1993;O’Donoghue and Rabin 2006).67While tobacco and alcohol can impose both direct externalities (e.g., second-handsmoke, disturbing others by making noise while drunk), and indirect externalities(e.g., medical costs for treating illnesses), the most important externalized costs ofconsumption of SSBs are indirect externalities. These financial costs associated withtreatment of diseases attributed to tobacco, alcohol, and SSB consumption are, atleast partly, financed by health insurance, and therefore born by the whole society.In other words, they are the costs of moral hazard (Allcott et al. 2019). Unlikeexternalities, internalities are born by the consumer. As explained above, they canhappen either because of imperfect information or just because the consumer maybe depreciating the potential future health costs associated to present consumption.Therefore, levying a tax on tobacco, alcohol, and SSBs would discourage consumptionand reduce both negative externalities and internalities, and would increase welfare.Extensive evidence on the responsiveness of consumption of addictive productsto price changes over the last few decades showed that, in contrary to the conventionalwisdom, the demand is in fact somewhat responsive in the short run, and moreresponsive in the long run (Chaloupka and Powell 2019). Most of the availableevidence is on the impact of prices on consumption of tobacco products and alcohol,while the evidence on SSBs is still emerging.Consumption of tobacco products in LMICs is most often more responsive toprice than in HICs, with estimates from LMICs ranging between −0.2 and −0.8,clustering around −0.5, and in HICs clustering around −0.4. Evidence, althoughmostly from HICs, shows that youths are more responsive to tobacco price increasesthan adults. Economic theory suggests several reasons why this is the case, includinglimited income, peer effect, and lower addiction level due to a shorter period ofconsumption since initiation. A few studies have also estimated the impact oftobacco price increase on consumption by gender, but have produced mixed evidence.Moreover, several studies have examined the substitution among tobacco products,particularly among similar products (e.g., between cigarettes, roll-your-own tobacco,and little cigars) as a result of their relative price changes (NCI and WHO 2016). Whileresults from HICs offer the evidence of substitution, the evidence from LMICs is mixed.Finally, as income increases, consumers tend to switch to more expensive products,such as from domestic to international brands (Chaloupka and Powell 2019).In terms of the responsiveness of different socioeconomic groups, the evidencefrom both HICs and LMICs has been rather mixed. In the U.S. while more studiesfind that lower socioeconomic groups are more responsive to tobacco price changethan higher socioeconomic groups (Farrelly et al. 2001; Chaloupka 1991; Colman andRemler 2008), some offer mixed evidence (Franks et al. 2007). In other HICs, such as UK68and Australia, evidence also suggests that smokers in higher socioeconomic groupsare much less impacted by price change than those in lower groups (Townsend et al.1994; Siahpush et al. 2009). Findings from LMICs have been more mixed (Chaloupkaet al. 2012; Levy et al. 2004). For example, while evidence from Bangladesh (Nargiset al. 2014), China (Verguet et al. 2015; Huang et al. 2015), or Indonesia (Adioetomoand Djutaharta 2005) shows significantly larger responses in lower income groupsthan among wealthier ones, findings from a few other countries, such as Nepal(Karki et al. 2003), Turkey (Onder 2002), or Thailand (Sarntisart 2003) have beenless consistent.While taxes on tobacco have been widely recognized as both a public healthand a revenue generating tool, taxation of alcohol has been mostly used as a revenueinstrument, but is increasingly gaining attention among policymakers as a tool forhealth promotion and disease prevention. There is a general consensus amongscholars that increasing prices of alcohol may reduce consumption by youth andalcohol addiction (Chaloupka et al. 2002). Moreover, an increase in alcohol taxes mayreduce motor vehicle accident mortality and suicide rates (Son and Topyan 2011).Evidence from HICs suggests that price elasticity ranges from −0.51 to −0.77, whilelimited studies from LMICs find it to be around −0.64 (Chaloupka and Powell 2019).Additionally, heavy drinkers are found to be less responsive, with price elasticityof around −0.28. Consumption of wine and spirits is more elastic (price elasticitybetween −0.68 and −0.80) than beer (between −0.36 and −0.46), and increase inincome is associated with higher increase in alcohol consumption (Wagenaar et al.2010; Gallet 2007). It has also been documented that alcohol users are more likelyto smoke and that, in such cases, focusing on only one policy rather than a synergywould result in much smaller health benefits (Son and Topyan 2011; De Silva et al.2011). Evidence on the different in response to change in alcohol price of differentsocioeconomic groups is missing.Unlike taxation of tobacco and alcohol which have been levied in almost allcountries, not as many governments levy a tax on SSBs. As of end of 2018, around40 countries levy some type of tax on sugary drinks (WCRF 2018). Based on the existingevidence, taxation of SSBs leads to their lower consumption and to substitution tobeverages with lower content of sugar (Backholer et al. 2018), with price elasticityclustering around −1.2 (Chaloupka and Powell 2019), and could reduce obesityrate (Escobar et al. 2013). Increasing prices on SSBs has a relatively larger positiveimpact on consumption in LMICs than in HICs. Evidence from Mexico, Ecuador,Chile, Guatemala, and South Africa finds price elasticity between −1.09 and −1.39(Chaloupka and Powell 2019). Additionally, in almost all countries, consumption69of bottom-income groups is more price elastic than of the higher-income groups(Sassi et al. 2018). Taxation of SSBs could have a substantial public health impact,while generating much needed revenues. A 2011 study from the US estimated that anational penny-per-ounce SSB tax would reduce consumption of SSBs by 24 percentwithin four years, and generate USD 79 billion of new tax revenues (Andreyevaet al. 2011). Mexico’s SSB tax, which was introduced in 2014, reduced sales ofSSBs by 5.5 percent in the first year, and by 9.7 percent in the second year after theimplementation (Colchero et al. 2017). Similarly, it has been estimated that the newlyadopted SSB tax in the Philippines could generate USD 813 million (0.25 percent ofGDP) per year in additional revenues, and USD 627 million (0.19 percent of GDP) inhealthcare savings (Saxena et al. 2019).In addition to their public health objective, excise taxes are also an importantsource of government revenues. One of the central actions of the 2015 Addis AbabaAction Agenda is domestic revenue mobilization, which has recognized tobaccotaxes as a key policy measure to reduce the burden of NCDs and help meet the SDGs(UN 2015a). This argument is supported by a great deal of evidence, including fromLMICs, demonstrating that tobacco taxes are a powerful tool for reducing tobaccoconsumption while providing a source of government revenues (Chaloupka et al.2012). For example, in South Africa, as a result of the tax increase, the real prices ofcigarettes increased by 115 percent between 1993 and 2003, consumption decreased byaround 40 percent, while real government revenues increased by almost 150 percent(Van Walbeek 2005). WHO has estimated that a 50 percent increase in taxes oncigarettes in LICs would generate enough additional revenues to finance more than25 percent of their current government health spending (Stenberg et al. 2010).Recent study commissioned by the Bloomberg Summers Task Force on FiscalPolicy for Health (Summan and Laxminarayan 2019) simulated health and revenueimpacts of different increases of price of tobacco, alcohol, and SSB through taxincrease, and found potential health and revenue benefits even in the short run. Thestudy assessed what would happen over a period of 50 years if all countries increasedtaxes enough to raise prices by 20, 30, 40, and 50 percent (Table 1). The results showedthe highest health impact of increased tobacco taxes, with around 11 million savedlives, with additional revenue of US$ 1.6 trillion in 2016 prices (around 1.3 percent of2016 global GDP (PPP$)) if prices increased by only 20 percent. Potential revenueimpact of alcohol taxes is the highest, mostly because current taxes are low. Alcoholprice increase by 20 percent could generate additional US$ 8.9 trillion (in 2016 prices),or 7.3 percent of 2016 global GDP (PPP$). Potential impact of increases taxes on SSBsis relatively lower than on tobacco or alcohol, as consumption is not as widespread70and only a set of products would be affected, and the estimate only captures theimpact on body-mass index (BMI), but does not capture other effects, such as reducedobesity. Nevertheless, its potential impact is not negligible.Table 1. Projected health and revenue impact of tax increase on tobacco, alcohol,and SSBs.Tobacco Alcohol SSBsPrice Increasevia Tax AvertedDeaths 1GainedYears ofLife 1TaxRevenueGain 2AvertedDeaths 1GainedYears ofLife 1TaxRevenueGain 2AvertedDeaths 1GainedYears ofLife 1TaxRevenueGain 220% 10.8 212.0 1.6 9.4 238.7 8.9 0.8 23.7 0.730% 16.3 321.4 2.2 13.7 348.7 12.2 1.3 35.0 1.040% 21.8 428.6 2.6 17.9 455.0 14.8 1.7 46.5 1.250% 27.2 535.7 3.0 21.9 557.8 16.7 2.2 57.8 1.41 In millions; 2 in trillions of 2016 USD. Source: The Task Force on Fiscal The Task Force onFiscal Policy and Health (2019); Summan and Laxminarayan (2019).One of the common concerns of policymakers against taxation of tobacco, alcohol,and SSBs is that they may be regressive, by mostly considering only the averageratio of the amount of tax paid and income. However, this measure does not takeinto account any health benefits of a tax from reduced consumption of unhealthyproducts. Lower income households most often respond to a price increase byreducing their consumption relatively more than the higher income households(Sassi et al. 2018). Moreover, as different socioeconomic groups can have differentprevalence of consumption, the tax burden may be relatively higher in those groupswith higher prevalence. As the goal of taxes on tobacco, alcohol, and SSBs is areduction in prevalence and quantity of consumption, it is therefore importantto account for a reduction in prevalence resulting from a tax when evaluating itsdistributional impact. In other words, in determining whether a tax is regressive orprogressive, one needs to know the consumption patterns across income groups andtheir responsiveness to price (Summers 2018).The distributional impact of these taxes depends on various factors, includingprevalence rates and price elasticities by socioeconomic group, access to healthcare,and other fiscal policies. The potential equity implications of these taxes needto be addressed through other fiscal policy measures, such as direct subsidies orother targeted strategies that would incentivize behavioral change in vulnerablesocioeconomic groups. Moreover, the revenue raised though taxes can be used fordevelopment spending. When they are used progressively or within a broader taxreform, they can relatively more benefit the poorer households. For example, thePhilippines generated an additional US$ 1.5 billion from increased tobacco taxes71between 2013 and 2015, and used most of this revenue to almost triple the nationalhealth insurance coverage for poor families (Nugent et al. 2018; Goodchild et al. 2017).Similarly, Denmark made changes in the income tax code to offset the potential equityimpact of the new tax on saturated fats in 2011 (Sassi et al. 2018).Furthermore, the burden of the tax should be put in the context of a burdenof NCD disease (Summers 2018). Given that lower socioeconomic groups beardisproportionally larger burden of NCD disease (IHME 2019), and are, therefore,more likely to die prematurely, the burden of disease is regressive. Moreover, theeconomic costs associated with these diseases are also regressive, as lower incomehouseholds are likely to bear relatively higher costs than the wealthier households.Therefore, an excise tax would, in fact, be progressive as the poor households wouldbenefit relatively more through a significant reduction of these costs. For example,a 50 percent increase in cigarette excise taxes in China was estimated to reduce thetobacco-attributed medical costs borne by lower income household by US$ 6.7 billion(Verguet et al. 2015). Similarly, if cigarette tax in Thailand was increased by 50 percent,it was estimated that, as a result of reduced consumption, the bottom-income groupwould bear only 6% of the new tax, and would benefit from 58 percent of avertedpremature deaths (Jha et al. 2012). In Finland, after the government reduced taxes onalcohol in 2003, alcohol-related mortality increased by 16 percent among men and31 percent among women (Herttua et al. 2008).Evidence from several countries shows that a tobacco tax is progressive becausehealth benefits from reduced consumption due to tax and price increase more thanoffset the increase in tax liability, especially for lower socioeconomic groups (Fuchset al. 2019). Another study compares the burden of excise taxes on tobacco andalcohol in Chile, Poland, and Turkey, and taxes on SSBs in a group of LMICs to assesstheir distributional impact (Sassi et al. 2018). The tax burden is found to be relativelylarger for the bottom-income quintiles in case of tobacco, and for the top-incomegroups in case of alcohol and SSBs. However, when only households who consumethese products are taken into account, the bottom-income groups bear the highest taxburden for all three products.Indeed, in some countries tax structures are designed in a way to keep the pricesof some products at a low level in order to keep them affordable for low-incomeconsumers. While the argument for such a policy is that it is “pro-poor”, in fact it isnot as it leads to lower income groups bearing a disproportionate share of the healthand economic burden of these products, due to their greater consumption (Bobaket al. 2000). As a result, such tax policy is indeed regressive. However, consideringthe empirical evidence presented above, even if the current tax is regressive, a tax72increase can be progressive. To the extent that concerns about the impact on the poorpersist, they can be addressed by using the additional revenues in ways that benefitthe poor, such as expanding health coverage for lower-income households.The Politics of Taxes on Tobacco, Alcohol, and SSBs: Selected ExamplesCommonly, governments’ reluctance to commit to a tax increase is due to alack of evidence on the relevance of these taxes for health and development, lowtechnical capacity of relevant government agencies, limited political commitment,and lack of coordination within the government. In addition, industry oppositionand interference play a significant role. As a result, the legislative process is usuallyslow and often delayed. The industries are very fierce in their campaigns against atax increase. They use their arguments strategically and present themselves as a veryrelevant stakeholder, with which they justify the need to be part of the policy dialogue.As a result, their interests often prevail against the public interests. However, it is nota random case that the proponents of the tax increase have successfully challengedthe industry influence in the policy formulation (McCambridge et al. 2018). Someexamples of successful policy reforms, despite very strong industry opposition, arepresented below.The Philippines had a long history of strong opposition from the tobacco industryto tax increases, and several politicians had close connections to the industry. Thingschanged in 2010 when Benigno Aquino III was elected as the new president, who,unlike his predecessors, did not accept the campaign contributions from the industry(Madore et al. 2015). Aquino had government reform and poverty reduction high onhis political agenda, which included increasing sin taxes. Strong opposition from theindustry was expected, and tobacco farmers and factory workers were mobilized toprotest the bill. At the same time, most legislators in the Ways and Means Committeein the House of Representatives had known connections to the industry. As aresult, the objectives of the proposed reform were strategically formulized aroundemphasizing that the additional revenues would be used for expanding the nationalhealth insurance (PhilHealth) coverage to low-income households and for economicdevelopment projects in tobacco growing provinces. Interestingly, empirical evidenceon the economic and health impact of smoking, including estimates of the economiccost, already existed in the Philippines, but no policymaker used this evidence in anyof the previous attempts to push for a tax increase (Madore et al. 2015).Despite strong opposition, the bill was passed and signed into Law in 2012,becoming effective in January 2013. A compromise was made with the tobaccoindustry in terms of the tax rate simplification—instead of an immediate transition73to a unitary system, a gradual move from the existing four-tier to a two-tier systemwas agreed on, with an implementation of the unitary system in 2017. Additionally,to gain the support for the reform of the alcohol tax, an agreement was made withSan Miguel Brewery, which represented 90 percent of the Philippines beer market, toinclude its popular premium beer brand in the lower of the price tiers of the fermentedliquor brands. While distilled spirits were taxed at a uniform rate starting 2013, thetwo-tier system for fermented alcohol transitioned to the uniform system in 2017. Asa result, cigarette taxes increased by 340 percent between 2012 and 2013, resulting in48 percent increase in the average price per cigarette pack. The collection of tobaccoexcise tax revenue in 2013 increased by 114 percent relative to 2012, while alcoholtax collections increased by 38 percent. Most of the additional funds (85 percentof tobacco tax and 100 percent of alcohol tax revenues) were earmarked for health,with 80 percent of the funds being used to increase the PhilHealth enrollment oflow-income Filipinos, achieving 100 percent enrollment among this income group.It was reported that smoking prevalence among adults declined from 29 percentin 2012 to 26 percent in 2014, with a highest reduction in the lowest-income group(from 38 to 25 percent) and among adults between 18 and 24 years of age (from 35 to18 percent) (Madore et al. 2015).Similarly, Ukraine has a long history of tobacco industry price manipulation andinterference in tobacco excise tax policy (Hoe et al. 2020). The goal of tobacco industrylobbying in Ukraine has, for a long time, been keeping tax and price increases at alow level to assure that the changes do not exceed the rate of inflation. However,despite their strong effort, for the first time since 1998, the increase in cigarette taxin 2008 finally outpaced inflation, and despite the 2009 economic recession, whichreduced the real affordability of cigarettes by half, the government continued tosubstantially increase the tax until 2017. This reform was supported by newly electedpresident Petro Poroshenko, who signed the EU-Ukraine Association Agreementin 2014. As a result, during this nine-year period, the average excise tax increased20 times and tobacco tax revenues increased 11 times, while smoking prevalencedecreased by 35 percent and consumption of cigarettes by 46 percent. Moreover, in2017, the government adopted a seven-year plan to further increase the specific excisetax by almost 30 percent in 2018 and annually by 20 percent between 2019 and 2024.In proceeding with the proposed reform, the government had three main concerns,including the impacts on revenue collection, the poor, and illicit trade. Extensiveempirical evidence was produced and provided to the Ministry of Finance offeringarguments and reassurance that these concerns were not justified.74As SSB taxes are relatively new, at least in comparison to taxation of tobacco andalcohol, not as many country examples are available to illustrate the political economyof the issue. That, however, does not mean that the resistance of the SSB industry hasnot been fierce. One good example is Mexico, where the SSB industry has long hadties with the Mexican government and society, including the former chief executiveof Coca Cola Mexico being elected President of Mexico in 2010 (James et al. 2020).There had been attempts before 2012 to introduce the SSB tax in Mexico, but theywere not successful. Opponents of the tax, including the SSB industry, sugar caneindustry, and retailers used to run aggressive campaigns, calling on the Congress tooppose the tax, arguing that the tax would be regressive, would reduce employment,and would not reduce obesity rates. Finally, in 2012, the supporters, including civilsociety, politicians, and academics, effectively organized and supported the SSB taxproposal. The proposal also received strong support from the President EnriquePeña Nieto.As the Ministry of Finance kept the tax plans secret, the opponents of thetax did not anticipate it and were not very active before the President announcedthe tax. One reason may be that they were relying on their historically strongties with the government. Once it was sent to the Congress for consideration, theSSB industry began aggressively lobbying against the proposal. However, by thetime the opponents managed to organize, the supporters already had messagesframed around all negative implications of excessive SSB consumption and producedevidence providing counter-arguments to the anticipated industry arguments. Asa result, the House of Deputies and the Senate passed the bill in October 2013(James et al. 2020).Scotland presents a case of implementing a minimum price per unit of alcohol,which was a successful policy reform, but not without a fierce opposition. Thepolicy was proposed in 2012 with an objective of reducing consumption and itsharmful impact. However, the Scotch Whiskey Association and the European tradeassociations for spirits and wines challenged it and took it to the EU Court of Justice.They argued that the policy would not be effective in meeting its objective, that itwould hurt the poor, lead to illicit trade, and harm businesses (Shona et al. 2014).While the court did not dismiss the case, in December 2015 it requested additionalevidence that an alternative policy, such as higher taxes, would not be effective inmeeting public health objectives. Based on this evidence, the UK Supreme Courtrejected the industry’s case in November 2017, and the law came into effect on1 May 2018.75Based on these examples, it is obvious that passing a tax on tobacco, alcohol,and SSBs is a difficult process and involves many factors. Factors that made adifference and provided support to the Ministry of Finance in proceeding with thereform were: high-level support and strong political will and collaboration betweendifferent parts of the Government working in partnership toward a common goal;thorough understanding of the political economy context in the country; availablestrong empirical evidence providing the counter-arguments to the concerns about thepotential impact of the policy; and support provided by civil society and internationalorganizations.4. ConclusionsAs it is becoming increasingly clear that economic prosperity and health areinterdependent and that NCDs are a serious obstacle for achieving several SDGtargets, fiscal policies targeting people’s incentives for healthy behavior are becomingmore and more appealing to the policymakers. When properly designed, thesepolicies can improve health and raise much needed revenues, while eliminatingthe potential equity impact of taxes, thereby supporting the achievement of SDGs.NCDs are disproportionally clustered in lower socioeconomic groups of a society,and are a significant contributor to impoverishment, thereby worsening inequality.Tax policies can avert impoverishment, enhance workers productivity and economicgrowth by discouraging consumption of unhealthy products and improving diet,thereby contributing to prevention and control of NCDs and reducing the burden,and incentivizing support of human capital development.Author Contributions: V.V. and F.J.C. conceptualized the manuscript. V.V. developed the firstdraft and F.J.C. provided inputs and edits. V.V. and F.J.C. finalized the draft. 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Foreword: Can Two Emergencies Make an Opportunity?In our country, like in many other regions worldwide, two major, apparentlyunrelated, crises are deeply impacting the wellbeing and health of the populationand the economy. There is, however, substantial indication that these two distinctemergencies are strictly interdependent, if not faces of the same coin, and that, thereof,systemic, cross-sectional strategies, implemented for and merging critical issues ofboth sides, could be highly effective in providing an answer, in the medium- andlong-term, to this highly demanding, global occurrence.The Italian agrifood system is of considerable importance both in terms ofturnover and number of businesses and employment for the characterization of theMade in Italy and, more in general, the Italian lifestyle across the world. The Italianfood industry faces today a phase of profound evolution based, on one hand, on theinternal dynamics of the system and, on the other, on the more general process ofglobalization that profoundly affects the entire world economy. These changes areinfluenced by and, in turn, influence new consumer behavior trends, though factorsassociated with regional level and individual cultural diversities significantly andsystematically impact impulsive purchasing behavior (Kacen and Lee 2002).The radical changes in the production, commercial and distribution systemsrelated to food products have generated socio-economic changes that have in turnmodified consumers’ eating habits (Greendex 2014). In recent decades, we havewitnessed weighty social phenomena, such as the destructuring of the familynucleus, the increasing inclusion of women in both the labor market and economicactivities, the spread of the market nonstop opening hours and the steady increase inout-of-home food consumption, which have all determined a profound reorganizationof life rhythms and contributed to generating significant changes in eating patterns.The latter are also featured by an ever increasing degree of processing, hence favoring adecrease in the time allocated for food preparation and consumption and determining89a consequential preference for products with a higher content of additional servicesthat consumers are willing to purchase at higher prices.Another phenomenon that has expanded in recent years is the demand for safefood products with stable quality over time, providing the consumer with a highlevel of satisfaction based on taste (Grunert 2005). This is, in turn, closely connectedto other important aspects, such as the impact on both individual and collectivehealth status and well-being, the genuineness and naturalness of the agriculturalraw materials used, the link with the territory, its history and traditions, factors thathave all contributed to the realization of systems for the traceability of food productsand the valorization of different food and wine cultures dispersed throughout thenational and regional territories, including our own. Furthermore, recent changesin the Italian agrifood system originate from the transformation of the distributionsystems, which have become increasingly similar to those already established in mostadvanced European countries, whereby, along with the considerable gigantism ofmajor companies in the large-scale retail trade that compete on prices and dictate theconditions for other companies to enter the market, there are small/medium-sizedagricultural and agrifood enterprises, generally characterized by low bargainingpower and limited capacity to occupy significant market segments. Moreover, thesecompanies, being generally based on atomistic structures, suffer the ensuing difficultyof developing innovative, competitive products on the market at large.As far as our regional agrifood sector is concerned, although it has the highestnumber of enterprises in the country, with the greatest percentages of agricultural areaused for vineyards, fruits and vegetables cultures, it has, on average, one of the lowestcompany dimensions, in terms of either hectares or employees per company (ISTAT2010). Furthermore, regional investments in the agrifood sector lie well below thenational average (nearly 50%), with the agriculture added value in Sicily plateauingand occupation units in the agroindustry having decreased over the last decade(INEA 2013). Additionally, small/medium enterprises (SMEs) in the field are oftenfeatured by a limited innovation potential, a poor integration with public-privateresearch institutions and an insufficient systematization and organization of theexisting resources in an extended territorial networking. This results in increasingdifficulties for SMEs to run both domestic and foreign markets with characteristics ofquality and competitiveness.According to WHO, noncommunicable diseases (NCDs), mostly represented bycardiovascular disease, cancer, chronic respiratory disease and diabetes, accountedfor 71% of the 57 million deaths worldwide in 2016 (WHO 2018a). In our own region,NCDs account for nearly 80% of all causes of death in both sexes (ReNCaM 2014).90However, the global risk of dying from any one of these four major NCDs in peopleaged 30 to 70 years has steadily decreased in the last two decades (from 22% in2000 to 18% in 2016) (WHO 2018b). On the other hand, several epidemiologicalstudies clearly indicate that all Western countries, including Italy, are witnessing realepidemics of these NCDs and both adult and childhood obesity, mostly because ofthe dramatic changes that have occurred in both food systems and consumer eatinghabits and behavior globally (Hunter and Reddy 2013). Furthermore, the appearanceof many chronic diseases is occurring today at an average age earlier than ever, with aprogressive leftward shift in the onset age of various illnesses, including diabetes,cancer and obesity (Gale 2002).Paradoxically, or subsequently if you like, these changes have produced themost profound and rapid consequences in Southern European countries, includingItaly, Greece, Portugal and Spain, eventually leading to a significant increase inincidence rates of NCDs, along with high percentages of overweight and/or obesechildren (Wijnhoven et al. 2014), as a result of cultural, social, economic and genetictransformations. The progressive decline in mortality from NCDs, combined with therise in their incidence worldwide, has produced an alarming “scissor” phenomenon,consisting in a remarkable and continuous increase in the total number of chronicallyill individuals, that is to say of NCD prevalence (Hunter and Reddy 2013). This trendcauses economic, social and health issues of outstanding relevance worldwideand eventually led the World Health Organization (WHO), along with all majorhealth institutions, to launch a pluriannual action plan (2013–2020) for the primaryprevention and control of NCDs based on intersectorial strategies targeting theremoval of key risk factors for these diseases, including tobacco use, air pollution,physical inactivity, harmful use of alcohol and, notably, unhealthy diet (WHO 2013).In this framework, the increasingly high prevalence of NCDs is basically aconsequence of the transition from traditional to contemporary dietary patternsand physical activity. This shift, often named nutritional transition, is based on theincreasingly large availability of inexpensive, high calorie-dense food, quite oftenat the expense of biodiverse, local and healthier products. In particular, processedand ultra-processed food, rich in salt, refined sugar or sweeteners, saturated andtrans fats, is largely outpacing healthy food, rich in micronutrients, including freshfruits, vegetables, legumes and nuts. Furthermore, while the intake of unrefined,whole grains is fading and that of fruits and vegetables remains largely insufficient,the consumption of meat, dairy products and sweetened drinks has markedlyexpanded in most regions around the world. In a recent Italian study, Giampaoli andcolleagues compared the food consumption of a self-reported survey recorded in911960 in a southern Italian village (Nicotera) with that of an OEC/HES survey carriedout in 2008–2012 on 1968 men and 2062 women, aged 40–59 years. The authors foundthat the consumption of cereals has dropped to less than 40% in both sexes, while theintake of meat, dairy products, milk and sweets has increased from 2- up to 4-fold(Giampaoli et al. 2015).By definition, a food system comprises “all the elements (environment, people,inputs, processes, infrastructure, institutions) and activities that relate to thepre-production, production, processing, distribution, preparation and consumption offood and the outputs of these activities, including socioeconomic and environmentaloutcomes” (High Level Panel of Experts on Food Security and Nutrition 2017).In this wider context, individuals procure and consume food in the food environment,defined as “the interface that encompasses external dimensions such as the availability,prices, vendor and product properties, and promotional information, as wellas personal dimensions such as the accessibility, affordability, convenience anddesirability of food sources and products” (Turner et al. 2018).A number of disparate factors determine the structure of food systems (seeFigure 1). 5 Infant feeding and care Breast milk produc on and consump on, milk banks, maternity leave, legal protec on, Interna onal Code of Marke ng of Breast-Milk subs tutes, breast feeding friendly society Transporters Agribusiness Distributors Storage and distribu on Farmers, indigenous people, agribusiness, land and implanta on owners, fish eries, financial en es Produc on system Packing plants, food and beverage industry, small and medium enterprises Processing and packaging Retailers, vendors, food outlet owners, traders, restauranteurs, wholesalers Marke ng and retail Food supply chains Food availability and physical access (proximity) Economic access (affordability) Promo on, adver sing and informa on Food quality and safety Food environments Choosing where and what food to acquire, and how to prepare, cook, store, and eat it Consumer behavior Quan ty Quality Diversity Safety Diet composi on Nutri on and health outcomes Social, economic and environmental impacts Poli cal programmes and ins tu onal ac ons Figure 1. Schematic representation of food system and its outcomes. Source: Modified from Branca et al. (2019), used with permission. They relate to a vast array of drivers and policies, as described by Branca and colleagues (Branca et al. 2019). The former include demographic issues, globalization, urbanization and climate changes. The latter comprise environmental, agricultural, commercial and economic policies, either locally or globally. According to Turner and associates (Turner et al. 2018), food environments consist of both external and personal domains, whereby a variety of dimensions coexist and shape the environment: the external domain comprises subjects relevant to food availability and prices, characteristics of vendors and products, marketing and its regulation; the personal domain is based on individual dimensions, including food accessibility, affordability, convenience and desirability. The authors consider that people’s food acquirement and consumption is generated by a series of intricate interactions between these domains and their assorted dimensions. In the food environment, consumer behavior has a central role and is subjected to a multiplicity of influencing factors, belonging to cultural background and individual knowledge; personal preferences; food availability and accessibility, either physical (reachability) or economic (affordability); time and effort allocable for food purchase; preparation; cooking; and consumption. In recent decades, consumer behavior has been the primary target of aggressive marketing strategies of major food companies and large retail chains, eventually corrupting the food system and delivering mostly inexpensive, unhealthy food, with devastating effects on public health, especially for low-income, developing countries and vulnerable and marginalized populations. Today, although citizens are are literally soaked in a liquid milieu of innumerable news, information, reports, forums, blogs, advertisements and mass and social media, all available on the internet, quite often most of them come from an extremely large and doubtful variety of sources that Figure 1. Schematic representation of food system and its outcomes. Source:M dified from Branca et al. (2019), used with permission.l i licies, as described by Branca andcolleagues (Branca et al. 2019). The former include demographic issues, globalization,urbanization and climate changes. The latter comprise environmental, agricultural,92commercial and economic policies, either locally or globally. According to Turnerand associates (Turner et al. 2018), food environments consist of both externaland personal domains, whereby a variety of dimensions coexist and shape theenvironment: the external domain comprises subjects relevant to food availabilityand prices, characteristics of vendors and products, marketing and its regulation;the personal domain is based on individual dimensions, including food accessibility,affordability, convenience and desirability. The authors consider that people’s foodacquirement and consumption is generated by a series of intricate interactionsbetween these domains and their assorted dimensions.In the food environment, consumer behavior has a central role and is subjected toa multiplicity of influencing factors, belonging to cultural background and individualknowledge; personal preferences; food availability and accessibility, either physical(reachability) or economic (affordability); time and effort allocable for food purchase;preparation; cooking; and consumption. In recent decades, consumer behavior hasbeen the primary target of aggressive marketing strategies of major food companiesand large retail chains, eventually corrupting the food system and delivering mostlyinexpensive, unhealthy food, with devastating effects on public health, especiallyfor low-income, developing countries and vulnerable and marginalized populations.Today, although citizens are are literally soaked in a liquid milieu of innumerablenews, information, reports, forums, blogs, advertisements and mass and social media,all available on the internet, quite often most of them come from an extremely largeand doubtful variety of sources that can heavily affect and/or undermine consumerbehavior and beliefs. Luckily enough, however, the basic idea that food is importantfor human health has pervaded the general population at large and generated anincreasingly greater demand for healthy food, with a greater intake of fruits andvegetables and a growing interest in products containing superfoods as healthfulingredients. In this highly fragmented and complicated context, there is an urgentneed to develop policies, programs and campaigns for the nutritional counselingand education of citizens based on scientific, solid evidence and shared, verifiableinformation.Based on this combined consideration, promoting both the production andcompetitiveness of traditional food products—in regional, domestic and internationalmarkets, through a series of activities aimed at increasing their health and/ornutraceutical potential, to clinically validate their effects on both health and chronicdisease(s); to enable the rapid technological transfer and industrial development ofeither processes or products; and to exploit large, population-based interventionsof nutritional and behavioral education to develop individual knowledge and93competences (empowerment) concerning lifestyle, nutrition and health—wouldrepresent a systemic strategy of high impact in the short, medium and long termfor important expected outcomes from an economic, technological and healthcarestandpoint.2. The DiMeSa StudyThe DiMeSa study1, where DiMeSa stands for Dieta Mediterranea e Salute,simply Mediterranean Diet and Health, was funded by the Italian Ministry ofUniversity and Research (MIUR) to the leader Institution, the AgroBioPescaTechnology Cluster. The project, which ran from October 2012 up to December2015, was named “DiMeSa—Valorization of typical products of Mediterranean Dietand their use for health and nutraceutical purposes” and aimed at increasing theattractiveness and competitiveness, in either the domestic or international market,of traditional products from major regional agrifood chains. In particular, the mainobjective of the DiMeSa project was, using different approaches, to develop and exploitinnovative industrial research and experimental activities that would eventually leadto improving the health potential of traditional food products and that, at the sametime, would scientifically validate the existing relationship between these productsor their components and health, both in terms of maintaining, both individuallyand collectively, a wellbeing condition and, especially, of the primary preventionof NCDs.As illustrated in Figure 2, the DiMeSa project was arranged into 4 major objectives,precisely:1. the analysis and identification of traditional food processes and the developmentof innovative biotechnological protocols for the production of food with highnutritional and health potential, including extra virgin olive oil, cereals orvegetables and their transformed derivatives;2. the definition and implementation of procedures and methodologicalapproaches for the production of functional foods (extra virgin olive oil, pasta,juices) through their combination (functionalization) with natural substancesand/or plant/byproducts extracts with high health potential and their distributionthrough innovative vending machines;3. the clinical validation of specific health claims through the implementationof randomized, controlled clinical trials to assess the health effects of selected1 Based also on previously published work by Carruba et al. (2016).94functional food products on cohorts of either healthy, high-risk or diseasedstudy-subjects through the evaluation of the impact of dietary interventionon some clinical and biomolecular end-points, such as: (a) anthropometricmeasures; (b) immunological markers of inflammation; (c) oxidative stress andendothelial function; (d) hormonal profiles and gene/miRNA expression;4. the economic evaluation of the concept, traceability and industrial scale-upof either prototypal products or processes aiming to allow their immediateindustrialization and successful marketing. 7 food with high nutritional and health potential, including extra virgin olive oil, cereals or vegetables and their transformed derivatives; 2. the definition and implementation of procedures and methodological approaches for the production of functional foods (extra virgin olive oil, pasta, juices) through their combination (functionalization) with natural substances and/or plant/byproducts extracts with high health potential and their distribution through innovative vending machines; 3. the clinical validation of specific health claims through the implementation of randomized, controlled clinical trials to assess the health effects of selected functional food products on cohorts of either healthy, high-risk or diseased study-subjects through the evaluation of the impact of dietary intervention on some clinical and biomolecular end-points, such as: (a) anthropometric measures; (b) immunological markers of inflammation; (c) oxidative stress and endothelial function; (d) hormonal profiles and gene/miRNA expression; 4. t e economic evaluation of the concept, traceability and industrial scale-up of either p ototypal products or processes aiming to allow their immediate strialization and suc es ful marketing. OBJ 1 ANALYSIS AND IDENTIFICATION OF TRADITIONAL FOOD PROCESSES AND SET UP OF BIOTECHNOLOGICAL PROTOCOLS FOR THE PRODUCTION OF FOOD AT HIGH HEALTH POTENTIAL OBJ 2 IMPLEMENTATION OF OPERATIVE METHODS FOR THE PRODUCTION OF FUNCTIONAL HEALTHY FOOD AND NUTRACEUTICALS OBJ 3 C LINICAL VALIDATION OF HEALTH CLAIMS OBJ 4 E CONOMIC EVALUATION OF THE CONCEPT, TRACEABILITY AND INDUSTRIAL SCALE- UP Figure 2. Framework of the Dieta Mediterranea e Salute (DiMeSa) project and its 4 major objectives. Source: Figure by the author. The DiMeSa project was a multicenter study, characterized by a large regional partnership, which included universities and other public research institutions, on one hand, and small/medium enterprises (SMEs) in the field, on the other (see Figure 3). 2. Framework of the Dieta M diterranea e Salute (DiMeSa) project and its 4major objectives. So rce: Figure by the author.The Di eSa project was a ulticenter study, characterized by a large regionalpartnership, which included universities and other public research institutions, on onehand, and small/medium enterprises (SMEs) in the field, on the other (see Figure 3).95PUBLICUniversity of Palermo– SAF– DIFI– DIBIMEF– SEMBIO– CGA– DICGIMUniversity of Catania– Dip. Clinico-Sperimentale di Medicina e Farm.– D3DiNational Research Council (CNR)– IBF-Palermo– IBIM-Palermo– ICAR-Palermo– ISAFOM-UOS-CataniaBallatore ConsortiumCoRiSSIAIZSSSMESCoRiSvl– Oleifico San Calogero– Az. Agr. Angela Consiglio– Azienda “GeOlive” Belice– Pastificio Tomasello SpA– Laboratorio di Ricerche LocorotondoInnova Agro Sicilia– Molino di Sicilia SrL– Agriplast SrL– MedivisAgroindustry Advanced Technologues (AAT)Figure 3. Partnership of the DiMeSa project, including public research bodies andsmall/medium enterprises (SMEs). Source: Figure by the author.In the framework of the DiMeSa project, we conducted two main clinical trials,both belonging to Objective 3 of the project.In the first randomized study, we assessed the health impact of monocultivarextra virgin olive oils (EVOs) on 2 cohorts of study subjects represented byhealthy postmenopausal women and patients with breast cancer. All studysubjects were recruited at the Azienda di Rilievo Nazionale e di AltaSpecializzazione (ARNAS)—Civico, Di Cristina, Benfratelli (CDB). Overall, 103healthy postmenopausal women and 35 breast cancer patients were enrolled in thestudy. Two different mono-cultivar EVOs, one at a lower (Biancolilla cultivar, BL)and one at a higher (Cerasuola cultivar, CS) content of polyphenols and oleocanthal,were used in the study; both EVOs were produced by the Department of Agricultureand Forestry Sciences (SAF) of Palermo University, under the supervision of Prof.Tiziano Caruso. As regards healthy women, after an initial one-week wash-outperiod (“no EVO” week), the subjects consumed a daily amount of 30 mL of theBL EVO for 4 weeks, followed by another one week wash-out period (“no EVO”)and an additional 4 weeks intervention with the CS EVO, as illustrated in Figure 4.Conversely, breast cancer patients were randomized into one BL EVO and one CSEVO intervention group that consumed daily amounts of 30 mL of either BL orCS EVO for 4 weeks (see Figure 4). Both healthy and breast cancer study subjects,before and after any EVO intervention, undertook the following: (a) compiled a foodfrequency questionnaire originally developed for the EPIC study (Pisani et al. 1997);96(b) measured anthropometric indexes, including height, weight and waist-to-hipratio; (c) were administered psychometric tests (HADS, SF-36); (d) collected bothfasting blood samples and 12 h urine samples. The latter samples were used todetermine the potential effect of dietary intervention on an array of both plasmaticand serum biomarkers, the expression profiles of a set of previously selected genes,the whole miRNome and the urinary profile of sex steroid hormones.Healthy PostM (103)Olive oil at lower content of polyphenols and oleocanthal (4 weeks)Olive oil at lower content of polyphenols and oleocanthal (4 weeks)Olive oil at higher content of polyphenols and oleocanthal (4 weeks)Olive oil at lower content of polyphenols and oleocanthal (4 weeks)Wash-out (1 week)Wash-out (1 week)Breast cancer patients (35)Figure 4. Flow chart of a randomized clinical trial in the DiMeSa project to assessthe effects of selected monocultivar extra virgin olive oil on selected parameters inboth healthy postmenopausal women and breast cancer patients. For explanation,see text. Source: Figure by the author.Biological samples (plasma, serum and urine) were collected and stored in abiobank until analyses. A web-based study database was also created and dataprocessed using advanced statistical analysis and appropriate software.As reported in Table 1, the consumption of BL EVO resulted in significantchanges of various plasmatic biomarkers in both healthy subjects and breast cancerpatients. In particular, the reduction in glycemia, insulinemia and total cholesterollevels appears to be of special interest.On the other hand, the consumption of CS EVO produced several modificationsin selected biomarkers (see Table 1), including a significant increase in HDLcholesterol and reduction in LDL cholesterol. Interestingly, this EVO also induceda marked decrease in the plasmatic levels of estradiol. It appears noteworthy that,when comparing the two EVOs, BL EVO appeared to be more effective in reducingglycemia, while CS EVO proved to be more effective in decreasing plasmatic estradiol(see Table 2).97Table 1. Effects of BL and CS extra virgin olive oil (EVO) on plasmatic biomarkersin both healthy postmenopausal women and breast cancer patients.BL Extra Virgin Olive Oil CS Extra Virgin Olive OilVariable Baseline After p-Value * Variable Baseline After p-Value *Azotemia 30.85 28.48 0.002 Cretininemia 0.69 0.63 <0.001Uricemia 4.17 4.29 0.001 Uricemia 4.23 4.43 0.002Glycemia 85.35 83.59 0.021 Glycemia 89.16 88.48 0.023Insulinemia 10.33 8.79 <0.001 Glycatedhemoglobin 5.64 5.51 <0.001Totalcholesterol 207.48 197.12 <0.001HDLcholesterol 57.87 59.31 0.023Gamma GT 21.90 24.50 0.001 LDLcholesterol 119.62 102.12 0.047TotalProteinemia 7.00 6.91 0.005 Testosterone 0.39 0.36 0.033Sideremia 76.95 67.02 <0.001 Estradiol 31.40 23.95 0.002* paired T test, ANOVA. BL, Biancolilla cultivar; CS, Cerasuola cultivar. Source: Carruba et al. 2016.Table 2. Comparison of the effects of BL and CS EVO on glycemia and estradiollevels in both healthy postmenopausal women and breast cancer patients.Variable BL EVO CS EVO p-ValueGlycemia 83.59 88.48 0.023Estradiol 37.21 23.95 0.027BL, Biancolilla cultivar; CS, Cerasuola cultivar. Source: Carruba et al. 2016.This would imply that different EVOs may have distinct impacts on eitherglycemic control or hormonal (sex steroid) status, also depending on the cultivar andon the phenology of fruit ripening (the earlier the stage, the greater the content ofpolyphenols).The results of gene expression, microRNA profiling and patterns of urinary sexsteroids are currently under complex analysis and are awaited with great expectationand interest.In the context of the DiMeSa project, we conducted another clinical trial toassess the impact of a pasta product supplemented with an extract of cladodes ofOpuntia Ficus Indica (OFI) on the lipid profiles of subjects presenting with at leastone component of the metabolic syndrome (MS).98As illustrated in Figure 5, eighty-six healthy subjects of both sexes, among over2500 employees, participated voluntarily in the study at the Division of Researchand Internationalization of the ARNAS-Civico, Di Cristina, Benfratelli healthcarecomprehensive center (Palermo, Italy) for 8 months.Out of these 86 subjects, 52 aged 40–65 years (13 male and 36 female; age:56 ± 5 years) were recruited in the study based on the inclusion criterion of presentingwith one or more risk factors of MS according to the American heart Association(AMA), precisely: (a) fasting glucose ≥ 100 mg/dL (or receiving drug therapy forhyperglycemia); (b) blood pressure ≥ 130/85 mm Hg (or receiving drug therapyfor hypertension); (c) triglycerides ≥ 150 mg/dL (or receiving drug therapy forhypertriglyceridemia); (d) HDL-C < 40 mg/dL in men or <50 mg/dL in women (orreceiving drug therapy for reduced HDL-C); (e) waist circumference ≥ 102 cm in menor ≥88 cm in women.Dietary intervention consisted in the weekly consumption of 500 g of thedried pasta functionalized with a 3% soluble extract of OFI cladodes for a totalof 4 weeks and was maintained as an add-on to the cardio–metabolic therapiesalready in use. At baseline and at the end of dietary intervention, all study subjectsunderwent the following: (1) anthropometric measures; (2) psychometric tests;(3) medical examination; (4) biochemical assessment of circulating biomarkers,with special emphasis on the LDL-C subfractions (conducted at the Unit of Diabetesand Cardiovascular Prevention at the University of Palermo, Italy—Proff. G. Montaltoand M. Rizzo).N86 Subjects (45–65 yrs) volunteerdN 52 Subjects (40–65 yrs) at risk of Metabolic SyndromeN 49 Subjects (40–65 yrs) completed the trial*Anthropometric measures, psychometric tests, biochemical analyses4 week dietary intervention with pasta functionalized by 3% extract of Opuntia Cladodes 500 gr/weekFigure 5. Flow chart of a randomized clinical trial in the DiMeSa project to assess theeffects of pasta supplemented with a 3% extract of cladodes of Opuntia Ficus Indicaon selected parameters in subjects at risk of metabolic syndrome. For explanation,see text. Source: Figure by the author.In particular, the LipoPrint System (Quantimetrix Corporation, Redondo Beach,CA, USA) was used to separate and measure LDL-C subclasses, as described elsewhere99(Hoefner et al. 2001). LDL subclasses were divided into seven bands (LDL-1 to LDL-7,respectively), LDL-1 and -2 being defined as large LDL, while LDL-3 to -7 weredefined as small LDL (Rizzo and Berneis 2006). At baseline, all participants wereasked not to vary their food and/or physical activity during the period of the study.After a complete description of the study, written informed consent was obtained fromall participants. The procedures adopted were approved by the Ethics Committees(EC) of both ARNAS-Civico (EC2) and the Policlinico University of Palermo (EC1).Overall, 49 subjects completed the study.After 4 weeks dietary intervention with the OFI-supplemented pasta, a limitedbut significant decrease in waist circumference was observed, while neither bodyweight nor body mass index (BMI) showed any significant change (Table 3).Table 3. Changes of biometric parameters after 4 weeks dietary intervention withOpuntia Ficus Indica (OFI)-supplemented pasta.Variable Baseline 4 Weeks p Value *Weight (kg) 69.5 (14.6)67.8 (47.9–125.4)69.8 (14.1)69.1 (47.8–123.4) 0.8665Waist circumference (cm) 92.3 (12.3)92 (73–132)91.4 (10.5)91 (72–129) 0.0297BMI (kg/m2) 25.9 (3.9)25.3 (20.8–41.4)26.1 (3.7)25.5 (20.8–40.8) 0. 8788Values are mean (±SD) and median (min–max). * Wilcoxon paired test. Source: Carruba et al. 2016.Furthermore, dietary intervention resulted in a statistically significantmodification of several biochemical plasmatic parameters, including a significantreduction in blood urea nitrogen (BUN), creatinine, glucose, triglycerides, aspartatetransaminase (AST) and sideremia; conversely, some hormonal parameters, includingestrogens (estradiol and estrone) and sex hormone binding globulin (SHBG), showeda significant increase. As far as plasma lipids are concerned, total cholesterol (TC),low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol(HDL-C) remained unchanged (see Table 4).Interestingly, dietary intervention with the OFI-enriched pasta produced asignificant increase in LDL-1 (from 49.6 ± 0.3 to 65.1 ± 0.2%, p = 0.0002) and aconcomitant reduction in LDL-2 (40.1 ± 0.3 to 29.7 ± 0.2) and LDL-3 (8.3 ± 0.2 to4.6 ± 0.1%, p = 0.0004). In addition, LDL-4 and LDL-5 also subclasses decreased,though differences were not statistically significant (see Table 5). No correlation wasfound between changes in sdLDL and any other metabolic parameter.100Table 4. Changes of plasmatic parameters after 4 weeks dietary intervention withOFI-supplemented pasta.Variable Baseline 4 Weeks p ValueBUN (mg/dL) 32.7 (7.9)33 (17–51)43.3 (9.3)43 (23–68) <0.0001 *Creatinine (mg/dL) 0.74 (0.1)0.71 (0.52–1.33)0.72 (0.1)0.71 (0.43–1.25) 0.0244 *Glycemia (mg/dL) 84.6 (12)84 (58–128)74.4 (14.2)72 (60–158) <0.0001 *HbA1c (%) 5.4 (0.4)5.3 (4.7–7.6)5.4 (0.4)5.3 (4.7–7.5) 0.9516 **Total Cholesterol (mg/dL) 208.3 (36.1)210 (115–267)209.9 (35.6)208 (129–266) 0.9620 **HDL (mg/dL) 60.7 (13.9)61 (30–88)60.6 (13.3)61 (30–88) 0.6672 **LDL (mg/dL) 139.3 (32.9)138 (65–195)139.3 (33.6)139 (78–200) 0.5274 **Triglycerides (mg/dL) 104.6 (53.6)82 (36–271)92.8 (54.7)71 (44–300) 0.0137 *AST (mU/mL) 28.3 (8.2)26 (17–63)23.7 (8.4)21 (15–62) <0.0001 **ALT (mU/mL) 22.2 (11.4)18 (8–65)22.6 (13.0)19 (8–69) 0.8830 **Gamma GT (U/L) 31.5 (27.5)27 (11–167)33.6 (39.2)25 (11–268) 0.3855 **Sideremia (µg/dL) 87.3 (21.3)87 (45–134)78.8 (28)78 (26–158) 0.0255 *Estradiol (pg/mL) 34.1 (27.2)22 (7–102)56.4 (58)43 (25–432) 0.0055 **SHBG (nmol/L) 66.5 (30.8)60 (18–143)81 (44)66 (21–195) <0.0001 **Estrone (pg/mL) 23.7 (23.2)15 (4–123)77.7 (35.2)64 (45–250) <0.0001 **Values are mean (±SD) and median (min–max). * Student’s paired t test; ** Wilcoxon pairedtest. Source: Carruba et al. 2016.101Table 5. Effects of OFI-supplemented pasta on LDL-C subfractions.LDL-C Fraction Baseline 4 Weeks p ValueLDL-1 49.6 ± 0.3 65.1 ± 0.2 0.0002LDL-2 40.1 ± 0.3 29.7 ± 0.2 <0.0001LDL-3 8.3 ± 0.2 4.6 ± 0.1 0.0004LDL-4 1.3 ± 0.1 0.6 ± 0.0 0.2987LDL-5 0.7 ± 0.1 0.0 ± 0.0 0.3223Data represent average ± SD of percent values. Source: Carruba et al. 2016.3. The PASSI ProjectAs a natural development of the DiMeSa project, we recently designed a newproject called the Produzioni Agroalimentari Sostenibili Salutistiche e Identificabiliin Sicilia—Sustainable, Healthy and Identifiable Agrifood Productions in Sicily(123 PASSI). The general framework of this project is illustrated in Figure 6. 14 Figure 6. The conceptual framework of PASSI project. This picture portrays the overall goal of the project and its domains, from farm to market, that will be primary focus of the project’s activities across major food chains. Additionally, the potential impact of key issues (from sustainability to marketing) on food system is also here highlighted as addressed in the project. The general goal of the PASSI project consists not only of the systematization of experimental evidence and results accomplished with the DiMeSa project, both in terms of processes and products, but also to overcome its intrinsic limits by creating a collection of functional food products, traditionally belonging to the regional agrifood system, through research and development actions set up in different domains (production, processing, packaging, distribution and trade) throughout each supply chain (horizontal objectives)—along with those relevant to sustainability (environmental and industrial), traceability, food security, health potential and equity of access (vertical objectives)—generating knowledge of the supply chain and its identity value and, therefore, increasing consumer skills and decision-making capacities (empowerment) also through the use of algorithms (Blockchain, Distributed Ledger Technology) for the traceability of food supply chains and their health value (see Figure 7). The general objective of this project consists of the promotion and valorization in either domestic or international markets of high-quality functional food products typical of the traditional region, which are sustainable, traceable and safe, and whose health effect is proven in controlled and randomized clinical trials. The specific objectives comprise the development and exploitation of supply chain programs (from field to table; from farm to fork) that allow the production, processing, packaging, distribution and marketing of high-quality foods with a high health potential in major regional agrifood chains, precisely: (a) the extra virgin olive oil (EVO) chain; (b) cereal chain; (c) citrus chain; (d) fresh and dried fruit; (d) vine and wine chain. The Figure 6. The conceptual framework of PASSI project. This picture portrays theoverall goal of the project and its domains, from farm to market, that will be primaryfocus of the project’s act vities across major od chains. Additionally, t potentialimpact of key issues (from sustainability to marketing) on food system is also herehighlighted as addressed in the project.The general goal of the PASSI project consists not only of the systematization ofexperimental evidence and results accomplished with the DiMeSa project, both in102terms of processes and products, but also to overcome its intrinsic limits by creatinga collection of functional food products, traditionally belonging to the regionalagrifood system, through research and development actions set up in differentdomains (production, processing, packaging, distribution and trade) throughouteach supply chain (horizontal objectives)—along with those relevant to sustainability(environmental and industrial), traceability, food security, health potential andequity of access (vertical objectives)—generating knowledge of the supply chain andits identity value and, therefore, increasing consumer skills and decision-makingcapacities (empowerment) also through the use of algorithms (Blockchain, DistributedLedger Technology) for the traceability of food supply chains and their health value(see Figure 7). The general objective of this project consists of the promotion andvalorization in either domestic or international markets of high-quality functionalfood products typical of the traditional region, which are sustainable, traceableand safe, and whose health effect is proven in controlled and randomized clinicaltrials. The specific objectives comprise the development and exploitation of supplychain programs (from field to table; from farm to fork) that allow the production,processing, packaging, distribution and marketing of high-quality foods with a highhealth potential in major regional agrifood chains, precisely: (a) the extra virginolive oil (EVO) chain; (b) cereal chain; (c) citrus chain; (d) fresh and dried fruit; (d)vine and wine chain. The activities to be developed consist of industrial researchand experimental development activities, structured according to an immediatetransfer of technologies and competences to the industrial setting for the productionand realization/marketing of processes/products widely used and consumed in theSicilian agro-industry. The project is divided into 8 implementation objectives (ORs),of which the first 5 (OR1–5) relate to food chain programs, while the remaining 3 (OR6–8) to transversal research activities (see Figure 7).The PASSI project is now being developed through its 9 implementationobjectives and also integrated with additional, though highly relevant, aspects,with special emphasis on the use of agricultural byproducts and co-products tofunctionalize food of high consumption in the general population.4. Conclusions and PerspectivesDoubtlessly, the primary prevention of NCDs through dietary interventions, inthe wider context of health promotion through a life-course approach, as endorsedby WHO, requires the design and exploitation of systemic strategies, implementedboth locally and globally, that would include radical changes in food systems andenvironments in order to provide identifiable, safe, healthy and affordable food to103the current population. Virtually all aspects of food chains, including pre-production,productive processes, transformation, packaging, distribution, marketing and retail,should be renovated according to comprehensive approaches and policies shared atregional, national and international levels. 15 activities to be developed consist of industrial research and experimental development activities, structured according to an immediate transfer of technologies and competences to the industrial setting for the production and realization/marketing of processes/products widely used and consumed in the Sicilian agro-industry. The project is divided into 8 implementation objectives (ORs), of which the first 5 (OR1–5) relate to food chain programs, while the remaining 3 (OR 6–8) to transversal research activities (see Figure 7). Figure 7. Structure of the 123 PASSI project. The project is divided into “horizontal” objectives (the traditional Mediterranean food chains: OR 1 to 5) and “vertical” objectives (from sustainability to marketing: OR 6 to 9), bridged by a sequential succession of activities (from production to trade) featuring the whole system. OR: implementation objective. Source: Figure by the author. The PASSI project is now being developed through its 9 implementation objectives and also integrated with additional, though highly relevant, aspects, with special emphasis on the use of agricultural byproducts and co-products to functionalize food of high consumption in the general population. 4. Conclusions and Perspectives Doubtlessly, the primary prevention of NCDs through dietary interventions, in the wider context of health promotion through a life-course approach, as endorsed by WHO, requires the design and exploitation of systemic strategies, implemented both locally and globally, that would include radical changes in food systems and environments in order to provide identifiable, safe, healthy and affordable food to the current population. Virtually all aspects of food chains, including Figure 7. Structure of the 123 PASSI project. The project is divided into “horizontal”objectives (the traditional Mediterranean food chains: OR 1 to 5) and “vertical”objectives (from sustainability to marketing: OR 6 to 9), bridged by a sequentialsuccession of activities (from production to trade) featuring the whole system. OR:implementation objective. Source: Figure by the author.In particular, the adoption of incentives for primary produce s and suppli rs toproduce and distribute healthy food sustainably should be accomplished. Conversely,fiscal policies to tax unhealthy, processed or ultra-processed food should also beimplemented. Changes in food storage, transportation and distribution, aimed atproviding easy access to nutritionally valuable, perishable food, should be introduced.It is well recognized that health determinants consist of a vast array of personal,relational, social, economic and environmental factors that influence, individuallyand collectively, health status. According to Dahlgren and Whitehead (1991),socio-economic, cultural and environmental conditions include education, agriculture104and food production as important pillars of wellbeing. In other words, health (inits in broadest sense) cannot be considered as an issue belonging solely to thewelfare sector; conversely, it must be dealt with using intersectoral, multidimensionalapproaches and systemic strategies. In this paper, the PASSI project proposes across-sectoral model for the production and marketing of high health potential foodproducts, addressing either internal (production, processing, packaging, distributionand trading) or external (sustainability, identity, traceability, safety, functionalityand marketing) factors of major food chains. This approach, intrinsically, impactsvarious SDGs included in the 2030 Agenda for Sustainable Development, precisely:(1) Goal 2: end hunger, achieve food security and improved nutrition and promotesustainable agriculture; (2) Goal 3: ensure healthy lives and promote wellbeing forall at all ages; (3) Goal 12: ensure sustainable consumption and production patterns.Furthermore, it is indirectly related to the following SDGs: (4) Goal 4: ensure inclusiveand equitable quality education and promote lifelong learning opportunities for all;(5) Goal 8: promote sustained, inclusive and sustainable economic growth, full andproductive employment and decent work for all; (6) Goal 15: protect, restore andpromote sustainable use of terrestrial ecosystems, sustainably manage forests, combatdesertification and halt and reverse land degradation and halt biodiversity loss.We recently designed an innovative, multi-actor approach based on theintegration of a variety of data, skills, expertise and competences to create aknowledgeable platform and a strategic plan for the sustainable consumptionand production of healthy, identifiable, safe and traditional food products. Thisproject, with the SHAPE acronym standing for Sustainable, Healthy and identifiableAgri-food Production Enterprise, represents the natural evolution of the PASSIproject, as it is molded upon a consumer-centered food system model that comprisesindividual taste and preferences; equitable access and affordability; socio-economic,psychosocial and behavioral determinants of food behaviors; cultural identity;innovative marketing strategies; and comprehensive nutrition education all with thegoal of strengthening the valorization of the health benefits of the Mediterraneandiet in different populations groups. This innovative model could be developed andimplemented in a series of “Mediterranean” countries, including Italy, Greece, Malta,Lebanon, Jordan (partners of the project), Portugal and Spain, where the dramaticchanges that have occurred in both food systems and consumer eating habits andbehavior in recent decades have led to a significant increase in the incidence ratesof NCDs, along with high percentages of overweight and/or obese children. In thisrespect, the innovative SHAPE approach could also be used, in the short and medium105term, as a primary prevention strategy to tackle the increasingly large prevalence ofnoncommunicable diseases in Mediterranean regions.Importantly, food environments should be transformed, before anything,culturally, by defining and implementing measures of nutritional education, fromprimary schools to adulthood, to seminally diffuse healthy behaviors not only interm of eating patterns but also regarding physical activity.In this respect, the Department of Health (DASOE) of the Sicilian Regioninitiated the Program named “Formazione Educazione Dieta” (FED), aimed at thepromotion and diffusion of healthy lifestyles, according to the Mediterranean Diet(Requirez et al. 2016). The major methodological strength of the FED programconsists of an intervention of health prevention and promotion based on two strategicelements: a centralized planning, adjustable according to outcome indicators, and amultiyear action plan, with cyclic activities throughout three regional networks(health, education and agribusiness). The program is synergistically focusedon: (a) a cascade training program, aimed at qualifying people to become experttrainers/educators able to influence the cultural changes, behaviors and lifestyles ofthe population, by acting specifically on the various recipients, in accordance withappropriate methodologies and evidence-based content; (b) the activation of localnetworks built to promote capillary activities in the regional territory (see Figure 8). 17 could be developed and implemented in a series of “Mediterranean” countries, including Italy, Greece, Malta, Lebanon, Jordan (partners of the project), Portugal and Spain, where the dramatic changes that have occurred in both food systems and consumer eati g habits and behavior in recent decades have led to a significant increase in the incidence rates of NCDs, along with high percentages of overweight and/or obese children. In this respect, the innovative SHAPE approach c uld also be sed, in the short and medium term, as primary pre ention strategy to tackle the increasingly large prevalence of noncommunicable diseases in Mediterranean regions. Importantly, food environments should be transformed, before anything, culturally, by defining and implementing measures of nutritional education, from primary schools to adulthood, to seminally diffuse healthy behaviors not only in term of eating patterns but also regarding physical activity. In this respect, the Department of Health (DASOE) of the Sicilian Region initiated the Program named “Formazione Educazione Dieta” (FED), aimed at the promotion and diffusion of healthy lifestyles, according to the Mediterranean Diet (Requirez et al. 2016). The major methodological strength of the FED program consists of intervention of health prevention and pr motion based on two strategic elements: a centralized planning, adjustable according to outcome indica-tors, and a multiyear action plan, with cyclic activities throughout three regional networks (health, education and agribusiness). The program is synergistically focused on: (a) a cascade training program, aimed at qualifying people to become expert trainers/educators able to influence the cultural changes, behaviors and life-styles of the population, by acting specifically on the various recipients, in accordance with appropriate methodologies and evidence-based cont nt; (b) the activation of local networks built to promote capillary activities in the regional territory (see Figure 8). Health Agrifood Educa on Scien fic board Execu ve board Stakeholders Health Agrifood Educa on 1st Level (central) 2nd Level (provincial) 3rd Level (regional) Integrated Territorial Network Figure 8. The FED operational model. The program is based on a cascade training system, governed by the Scientific Board and divided into 3 levels: (a) central, addressed to Figure 8. The FED operational model. The program is based on a cascade trainingsystem, governed by the Scientific Board and divided into 3 levels: (a) central,addressed to beneficiaries from Health, Education and Agrifood macroareas (1stlevel trainers); (b) provincial, addressed to beneficiaries from selected macroareasand stakeholders (2nd level trainers); (c) regional, with the creation of an IntegratedTerritorial Network consisting of representatives from the Scientific Board, 1st and2nd level trainers for seminal diffusion of education activities throughout the region.Source: Figure by the author.106Using an integrated multiprofessional approach, the experts develop anoperational and training program with centrality and uniqueness, making it uniformlyapplicable to the distinct organizational realities of the Sicilian territory.Today, just ten multinational companies control over 70% of the food supplyon the planet, owning nearly 500 different brands and providing the largest marketever of unhealthy, high-calorie food. Against their economic and organizationalsupremacy, governments should put in place strict policies to protect the productionand marketing of traditional food through investments in short-chained, territorialhealthy products.In this framework, outstanding importance is also assigned to the transitionfrom a linear economy to a circular economy in the agrifood industry, providingan array of opportunities at all stages, from primary production using precisionagriculture techniques, to the recycling and use of agricultural byproducts or wasteto produce functionalized, healthy food.In a holistic view, global efforts are being made through several internationalinitiatives, notably the 2030 Agenda for Sustainable Development including its17 Sustainable Development Goals (SDGs), to radically modify food systems andenvironments with the ambitious objective of preventing NCDs while protecting thehuman right of equitable, accessible and affordable nutritious food.Acknowledgments: The DiMeSa project was financed by a grant (PON02 00667-PON02 004513361785) from the Italian Ministry of University and Research (MIUR) to the The AgroBioPescaTechnology Cluster. The FED Regional Programme was officially adopted by the SicilianRegion with the 1778/13 decree of the Regional Ministry of Health on 30 December 2013.The author is grateful to both Mario Enea (University representative) and Ing. AntonioGiallanza (Project Manager), from the Department of Engineering of Palermo University, fortheir invaluable contribution to the DiMeSa and 123 PASSI projects. I also wish to thank TizianoCaruso and Giuseppe Di Miceli, from the Department of Agriculture and Forestry Sciencesof Palermo University, for their precious collaborative efforts, respectively, in the productionof monocultivar EVOs and the OFI-supplemented pasta in the DiMeSa study, and last butnot least, Nicola Locorotondo for his continuous enthusiastic support. 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Concepts andcritical perspectives for food environment research: A global framework with implicationsfor action in low- and middle-income countries. Global Food Security 18: 93–101. [CrossRef]World Health Organization. 2013. Global Action Plan for the Prevention and Control ofNoncommunicable Diseases 2013–2020. Geneva: World Health Organization.World Health Organization. 2018a. World Health Statistics 2018—Monitoring Health for the SDGs,Sustainable Development Goals. Geneva: World Health Organization.World Health Organization. 2018b. Global Health Estimates 2016: Deaths by Cause, Age, Sex,by Country and by Region, 2000–2016. Geneva: World Health Organization, Availableonline: http://www.who.int/healthinfo/global_burden_disease/estimates/en/index1.html(accessed on 24 April 2021).Wijnhoven, Trudy M. A., Joop M. A. van Raaij, Angela Spinelli, Gregor Starc, Maria Hassapidou,Igor Spiroski, Harry Rutter, Éva Martos, Ana I Rito, Ragnhild Hovengen, and et al. 2014.WHO European Childhood Obesity Surveillance Initiative: Body mass index and levelof overweight among 6–9-year-old children from school year 2007/2008 to school year2009/2010. BMC Public Health 14: 806. [CrossRef] [PubMed]© 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an openaccess article distributed under the terms and conditions of the Creative CommonsAttribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).109Impact of Public Health and Sustainabilityof Global Health Action for AchievingSDG 3Florian Fischer and Franziska Carow1. IntroductionIn current debates—be it on political, societal or economic levels—the term“globalisation” is used quite frequently. However, it tends to be misused andoverused, because there is missing clarity about its meaning and its impact onindividuals and society. Despite the complexity behind it, globalisation can besummarised as a social transformation, manifesting in spatial (e.g., migration, aswell as exchange of information, capital, goods and serves across national borders),temporal (e.g., caused by speeded up interaction through modern communication andtransportation technologies) (Oke 2009; Lee 2004), and cognitive changes—meaningthe way how we see ourselves and the world surrounding us. This leads to changes increating, exchanging and applying knowledge, ideas, norms, beliefs, values, culturalidentities, and other thought processes (Lee 2003, 2004; Bettcher and Lee 2002).Currently, humanity is facing a rapid global change, which differs substantiallyin its extent from previous episodes of global change (Sachs et al. 2019; NationalAcademies of Sciences, Engineering and Medicine 1992). Due to demographic,epidemiological, environmental, social, political, economic, technological, andcultural driving forces, we have encountered a “transformative change” whichis gaining momentum (Sachs et al. 2019). All of these forces are interconnected,leading to the overall complexity associated with changes in the health status ofindividuals and (sub-)populations. Health impacts of globalisation are positive andnegative at the same time. The impact may vary according to geographical location,sex/gender, age, ethnic origin, education level, and socioeconomic status (Lee 2004;Huynen et al. 2005).For that reason, globalisation causes divergence as it can be seen in severalexamples such as the global reorganisation of production and the emergence ofa global labour market, the incremental mobility of financial capital, the growingimportance of binding trade agreements and processes as well as global politicalagendas focusing on sustainability, and the persistence of debt crises particularly inlow- and middle-income countries (Schrecker et al. 2008). All of these examples are111not directly from the health(care) sector, but all of them impact on health. Therefore,reducing global burden of disease and improving health is an effort, which goesmuch beyond healthcare system and health policies. It needs to include policymakersand stakeholders at community, regional, country, and global level, originating fromall disciplines and policy fields. This relates to the “Health in all policies” approach,which determines the impacts of policymaking of all kinds and of all levels on healthand the health system. This approach supports policymakers to include healthin their decisions at the regional and national levels, but can also be adapted forsupranational level decision-making (WHO 2014).The United Nations declare health and well-being as a specific goal of theiroverall 17 worldwide Sustainable Development Goals (SDGs) (UN 2015b). In termsof ensuring healthy lives and promoting well-being for all at all ages—as claimedin SDG 3—this approach should be transferred to the global level. The targets andindicators for SDG 3 can be summarised as a call for universal health coverage,including quality essential access to health services, to sexual and reproductivehealthcare services, to safe and affordable medicine and vaccines for everyone, thereduction of the global neonatal and maternal mortality, as well as reduction ofsuffering and deaths caused by communicable and non-communicable diseases,pollution and accidents (UN 2016). For reaching these aims and allowing for asustainable development, an acknowledgement of sectors others than public health,e.g., food and agriculture industry and education, is crucial (Laaser and Epstein2010). Furthermore, this emphasises the need to consider the aims of all other SDGsalso in the context of their relationship to SDG 3, in terms of direct or indirect effectson health.Impacting on the health status of the world population as well as allowingsustainability in the context of public health and global health are challenging tasks.Within this contribution, we describe the challenges for public health on the globalscale. This is illustrated by four case studies, serving as examples for the relevance ofsustainability-focussed global health action for achieving SDG 3. This contributionprovides overarching suggestions and policy advice for further improvements tostrengthen a global response on today’s challenges and to gain the targets set withinthe SDGs.2. Global HealthGlobal health is defined as “an area for study, research, and practice thatplaces a priority on improving health and achieving equity in health for all peopleworldwide” (Koplan et al. 2009). Beaglehole and Bonita (2010) emphasise the aspect112of transnationality of research and action. The aim of global health is to overcome thenational–international divide and the divide between countries of different incomelevels through mutual exchange and partnership. This includes joint responsibility,funding, agenda setting, planning, and implementation (Berner-Rodoreda et al. 2019;Gautier et al. 2018; Koplan et al. 2009). This characterisation is at least partly inline with a dialectic approach for defining global health. According to this, “global”can be understood as “worldwide”, as “supraterritorial”, as “transcending nationalboundaries”, and as “holistic” (Bozorgmehr 2010). Therefore, global health has adefinitive political dimension. It corresponds with the aims of the SDGs for providinguniversal health coverage and leaving no one behind (UN 2015b) and, therefore,aims to reduce health inequities (in terms of unfair, avoidable differences arisingfrom poor governance, corruption or social exclusion) and health inequality (suchas the uneven distribution of health or health resources in or between populations)(Reidpath and Allotey 2007).2.1. Evolution of Global HealthGlobal health has experienced a major and rapid development in the past years(Martin et al. 2014). In general, global health is based on concepts, aims, and methodsof public health. It followed similar foci during its evolution, and has, therefore, beenfocussing mainly on disease prevention (particularly infectious diseases)—such as“old” public health”—by providing access to clean water and more nutritious food, bypromoting hygiene (e.g., due to body and hand washing, disinfection, town seweragesystems, quarantine laws), as well as by implementing population-based surveillanceand screening mechanisms (Kellehear 2017). The evolution of global health went onto follow the ideas of “new” public health, which takes a holistic and interdisciplinaryperspective on aspects related to health and well-being. Modern public healthis understood as “the science and art of preventing disease, prolonging life andpromoting health through the organised efforts and informed choices of society,organisations, public and private, communities and individuals” (Wanless 2004, p. 3).This definition includes health promotion, prevention, treatment and rehabilitationof disease, and the efforts of all stakeholders. Inter alia, public health genuinelydeals with the reduction of health inequalities and includes social determinantsof health—not only by prevention on a behavioural, but also on a structural level.Furthermore, public and global health have a focus on health policy and governance(Carlson et al. 2015; Barbazza and Tello 2014). The scope has widened becausedamage to the environment can also impact on health, as seen in the effects of climate113change, environmental degradation, and biodiversity loss (Roe 2019). For that reason,one can understand health as part of each of the 17 SDGs.2.2. Health as a Human Right and Global ImperativeIn the preamble of the World Health Organization’s (WHO) constitution, healthwas declared as “a state of complete physical, mental and social well-being and notmerely the absence of disease or infirmity” (WHO 1946). In 1948, the UniversalDeclaration of Human Rights pointed out that health is part of the right to an adequatestandard of living (art. 25) and was reaffirmed a human right in the Declaration ofAlma-Ata in 1978 (“Health for All”), which emerged as a central milestone in the fieldof public health, is it expresses “the need for urgent action by all governments, allhealth and development workers, and the world community to protect and promotethe health of all the people of the world” (WHO 1978). The 40th anniversary of thisdeclaration was used to renew its focus on the role of primary healthcare underthe lens of universal health coverage and the SDGs in the Declaration of Astana(Walraven 2019; Tilford 2018; WHO 2018a).The fact that there has been a legal basis for the right to health for over seventyyears, and that the goal of universal health coverage and equality have thus beenpolitical issues for such a long period of time, is accompanied by ethical considerations.This was particularly evident during the HIV/AIDS crisis starting in the 1980s, with thefollowing movement against the patent system for HIV/AIDS medication showinghow strongly human rights, ethics and health are related. The disparate burden of HIVin low-income countries in conjunction with the AIDS activist movement have led to aconsideration of health as a global imperative over the past three decades, and reviveda human rights-based approach to healthcare (Keusch et al. 2010). The activities ofsocieties and stakeholders worldwide put enough pressure on the system to decreasecosts for HIV/AIDS treatment by up to 99% (Meier et al. 2018). Since this period,an increasing number of countries have started to implement operating systems andpolicies that centre on health as a human right (Gostin et al. 2018).3. Challenges for Global Health ActionDespite the progress that has been made in global health in the past decades,several manifold and complex challenges are hindering the success of developing,implementing and evaluating effective and sustainable action plans to improvethe world population’s health. For example, Ridde (2016) emphasised the needfor more and better implementation science in global health, for bridging the“know–do gap” (Means et al. 2016). A common mantra in implementation science114in public health and global health is that we know what to do, but not how to doit: “Therefore, it is not enough to know if a health intervention is effective; it isalso necessary to understand why the intervention works, how, for whom and inwhich contexts” (Ridde 2016, p. 1). Impact evaluations need to go hand in handwith the evaluation of implementation. We need further evidence to understandimplementation processes, causal mechanisms, and contextual factors affecting theoutcomes of complex interventions in global health (Ridde et al. 2020). This has to goalong with a strong theoretical foundation (Ridde et al. 2020; Van Belle et al. 2017).Until now, implementation research in low- and middle-income countries has mainlyfocused on evaluating the effects of implementation strategies. Problems of scale-upand sustainability, which are key issues for global health interventions, have notadequately been addressed (Alonge et al. 2019).In addition to the lack of implementation research, another major challengeis to consider the diversity and heterogeneity in the needs of the manyeconomically, socially, culturally, climatically and demographically different regionsand subpopulations (Mason et al. 2017). Furthermore, there is not enough or onlyfragmentary research and limited data availability and/or quality in many countries,which additionally compounds estimating problems and needs on various levels(Asma et al. 2019). However, several attempts try to provide an overview in terms ofproblems and successes of global health as well as outline the progress in reachingSDG 3. Reporting on the global burden of disease and its development over timeand space and in relation to the SDGs is crucial, as performed by the Global Burdenof Disease study (Lozano et al. 2018), the United Nations (UN 2019b) and WHO(WHO 2019b).3.1. FinancingIn the past, global health, especially in industrialised countries, was seen from aperspective of providing development aid. Development projects have frequentlybeen implemented with a vertical structure. However, these top-down approachesused by several funders often had no (long-term) effects. Due to a lack of coordination,inefficient use of funding, and a strong focus on improving individual health withinthese approaches and programs directed at specific diseases—rather than publichealth or community approaches—many projects had no sustainable denouementand sometimes even led to adverse effects on the health status of the addressedcountry or region (Laaser and Epstein 2010; McCoy et al. 2009; Chang et al. 2019).Despite the overall steadily increasing amounts of money used for global healthfinancing, one major reason for the only modest achievements since the Declaration of115Alma-Ata is, therefore, its ineffective use (Laaser and Epstein 2010). The WHO pointsout that the global needs are clearly not being met by current funding. Althoughexternal funding (aid) represents less than 1% of global health expenditure (WHO2019b), only 0.3% of all direct grants were received by low-income countries in 2016(WHO 2018b), with an increasing trend for low-income countries and a decliningproportion of health spending in middle-income countries (WHO 2019b). At the sametime, the funding situation of the official development assistance (ODA), focussingon the poorest countries worldwide, has increased by 61% in real terms from 2010to 2019 (UN 2019a). Nevertheless, the rural poor of large middle-income countriesare neglected, although they are important target groups. It is important to notethat out-of-pocket spending especially affects the poor. In 2010, 11.7% of the globalpopulation spent at least 10% of their household budget on healthcare, an estimated1.4% worldwide were impoverished by financing healthcare the same year (WHO2018b). This inequality strongly addresses SDG 3, but also SDG 1 (“No poverty”),SDG 2 (“Zero hunger”), and SDG 10 (“Reduced inequalities”). For achieving thegoal of universal health coverage and better health and well-being, an efficient andeffective financing is fundamental.Furthermore, the United Nations and WHO state that workforce to providehealth services in many countries is not strong enough (WHO 2019b; UN 2019a).Within the last five years, 40% of all countries had fewer than ten medical doctors per10,000 people (UN 2019a). The education of medical staff is crucial to implementingessential healthcare and to covering the needs of low- and middle-income countries.This problem not only addresses SDG 3, but also SDG 4 (“Adequate education”),SDG 10 (“Reduced inequalities”), SDG 11 (“Sustainable cities and communities”)and SDG 16 (“Peace, justice and strong institutions”).All these aspects highlight the necessity for re-organising the ODA (Chan 2013),as “at least half of the world’s population does not have full coverage for essentialhealth services” (WHO 2018b). Additionally, a review and modelling of the past,present and future financing of global health, for the years 1995 to 2050, projectsa persistent and growing gap in per capita health spending, leading to growingdisparities between countries worldwide (Chang et al. 2019).3.2. ResponsibilityIn 2019, the WHO designated leadership and engaging partnership onhealth-matters, the setting of standards and monitoring their implementation, shapingthe research agenda, assessing health trends and articulating policy options as itscore-functions (WHO 2019a). Although many countries support the WHO and its116goals, the financing of the WHO is a problem that needs to be addressed. WHOcontinues to experience immense financial stress, as it is currently visible in publicdebates after the United States of America called to suspend their funds (Nature2020). This leads to questions about the future of WHO in global health governance(Reddy et al. 2018). The WHO is funded by mandatory and voluntary member statecontributions and other non-state organisations (Clift and Røttingen 2018). Cliftand Røttingen (2018) have stated that a shift to tied voluntary donations can beobserved within the last few years. This means that the WHO is not in power ofcontrolling how 80% of its budget is spent. Bennett et al. (2018) also claim that 80%of the funding of the WHO is earmarked for specific purposes. They emphasisethat many countries resist non-earmarked funding, because funders want to knowwhere the money goes and need to justify their donations. However, a focus onglobal priorities (i.e., non-communicable diseases and universal health coverage),which currently cannot be given enough attention due to funding, requires a moretransparent, flexible, and predictable fund allocation for the WHO (Bennett et al.2018; Reddy et al. 2018).Progress has been achieved in terms of responsibility, when the MillenniumDevelopment Goals (UN 2015a) were expanded by the amendment of sustainabilityin 2015. To accelerate this progress, 193 countries adopted the SDG Agenda 2030 atthe Sustainable Development Summit in New York, in September 2019. Additionally,countries and stakeholders can voluntarily undertake acceleration actions that“contribute to a speeded up implementation of the 2030 Agenda” (UN 2019b).The rationale for international cooperation is most compelling in the field of globalhealth, since global interdependence is most acute. Coherence across all areas ofpublic policy is needed to realise health equity and well-being for all. Governancemechanisms and intersectoral initiatives are needed and should be based on theSDGs, which provide a framework for strengthening policy coherence for achievinghealth equity (WHO Europe 2019).During the coronavirus pandemic the crucial need for scientific collaborationsin both the public and private sectors at the global scale became visible to developdiagnostics, vaccines and treatments in order to tackle health emergencies. However,this was also the time when we have seen various national responses, with a lackof globally coordinated approaches and missing responsibility for global action.Furthermore, the collateral effects of the COVID-19 pandemic caused by globaleconomic downturn, social isolation and movement restrictions, are unequallydistributed and mainly affecting those in the lowest power strata of societies(Shadmi et al. 2020).1173.3. Changing Patterns of Morbidity, Mortality, and Population DynamicsGlobal health actions need to encounter the demographic (Kirk 1996) andepidemiological transition (Omran 1971). The demographic transition describes apopulation’s shift from high mortality and high fertility to low mortality and lowfertility. However, this pattern in population dynamics does not happen uniformlyacross countries and regions worldwide. Therefore, some countries experiencedemographic ageing and population decline (particularly industrialised countries),whereas others are characterised by a robust population growth (Blue and Espenshade2011). Recent conceptual adjustments incorporated the nonlinear changes towardsvery low fertility and a diversity of union and family types (Zaidi and Morgan 2017).Despite these considerations, one needs to recognise that the demographic patternsaffect population’s health. The epidemiological transition describes the shift frominfectious diseases to non-communicable disease entities. However, this shift takesplace at different pace and from different starting points (Jamison et al. 2013).For example, neonatal, infant, and child mortality is still an important (global)public health challenge in low- and in some middle-income countries (Bursteinet al. 2019). The same applies to infectious disease. Infectious diseases are a majorrisk in low- and middle-income countries due to poverty, insufficient healthcare,unawareness or unavailability of preventive measures (Dye 2014), and the impact ofclimate change additionally facilitate outbreaks (Liang and Gong 2017). Vaccinationis known as one of the most cost-effective and successful public health interventionswith enormous contributions to global health (Greenwood 2014). A significantproportion of childhood mortality in low-income countries has been reduced dueto vaccination programs which promote herd immunity, eradicate diseases in thelong-term and by doing so ensure health and well-being (Glatman-Freedman andNichols 2012). For example, vaccination coverage for the prevention of diphtheria,tetanus and pertussis increased from 72% in 2000 to 85% in 2015 (UN 2019a) asa result of the Global Vaccine Action Plan (WHO 2013) and the Global Alliancefor Vaccines and Immunisation (GAVI), a public–private partnership committedto saving children’s lives and protecting people’s health by increasing access tovaccinations (GAVI 2019).In terms of global health—oriented toward the concepts of “old” publichealth—the Ebola (Honigsbaum 2017) and Zika (McNeil and Shetty 2017) outbreakswere obvious signals highlighting the need for pandemic preparedness for avoidingpublic health emergencies of international concern. Experiences gained during theglobal health crisis triggered by Ebola led to improvements in early response systems,in the development of interdisciplinary and intersectoral responses, and, most118importantly, in close cooperation between civil society and communities (Raguin andGirard 2018). The perspective of “new” public health also takes social determinantsinto account: for example, cholera is a strong indicator of inequality and lack of socialand economic development, because it disproportionately affects the world’s poorestand most vulnerable populations. Most of the time, cholera outbreaks occur as aresult of conflicts, natural disasters, famines, unsafe drinking water and deficientsanitation facilities (WHO 2018b). Cholera treatment requires early detection andimmediate healthcare and medication. For cholera outbreaks, the WHO recommendsthe establishment of surveillance systems and rapid response teams and calls forsupply readiness and higher laboratory capacities (WHO 2018b). SDG 3 is not theonly goal pertinent to the issue of preventing or eliminating infectious diseases:reducing inequalities (SDG 10); ensuring the availability and sustainable managementof water and sanitation (SDG 6); protecting, restoring and promoting sustainableuse of ecosystems, and halting biodiversity loss (SDG 15); taking action to combatclimate change and its impact (SDG 13); promoting peaceful and inclusive societiesfor sustainable development; providing access to justice for all and building effective,accountable and inclusive institutions at all levels (SDG 16) also relate to this issue.Furthermore, the global burden of non-communicable diseases is no longer justa phenomenon of high-income countries. Several non-communicable diseases aresocially patterned and related to behavioural risk factors such as tobacco smoking,alcohol consumption, low levels of physical activity, and unhealthy eating habits,which are getting much more common also in low- and middle-income countries(Marmot and Bell 2019; Stringhini and Bovet 2017). These countries are prone to sufferfrom a double burden of disease due to a high proportion of infectious diseases andnon-communicable diseases (Boutayeb 2006). For example, in 2016 almost 340 million(18.4%) children and adolescents (5–19 years) were overweight or obese globallyand, thus, at a high risk for suffering from non-communicable diseases later in life.The rate of obese children is higher in high-income countries, but the number ofobese children and adolescents in low- and middle-income countries is increasingfaster (WHO 2018b).4. Case Studies: Global Health and SustainabilitySustainability has become a central criterion in evaluating public healthprogrammes. In global health, a major shift took place from development tosustainability as well (The Lancet 2012). However, there are discussions about theconceptualisation and measurement of sustainability criteria. Overall, health is aninvestment that is itself sustaining and sustainable (Yang et al. 2010).119Global health action requires a mind shift towards a new political and socialmovement for health (Kickbusch 2014) which addresses the social, cultural, physical,environmental, commercial and political determinants of health. These approachesneed to ensure a balance between domestic and global action while recognising thecommitment to common goals such as the SDGs (Kickbusch 2016). Politicians andscientists representing a wide range of disciplines, businesses, civil society, and localcommunities, need to be new agents of change (Moallemi et al. 2019). A global andholistic perspective is needed for understanding (transnational) health issues andits determinants. This perspective needs to be applied at the local level to improvehealth and to gain sustainability (Rowthorn 2015). For highlighting the complexityof gaining impact and sustainability in global health and for showing the need ofparticipatory, inter- and transdisciplinary approaches, some examples in form of casestudies are delineated.4.1. Antimicrobial ResistanceThe rapid and ongoing spread of antimicrobial resistance poses a serious threatto global health (Watkins and Bonomo 2016; Hay et al. 2018). The indiscriminate useof antibiotics in human medicine and agriculture are a main driver contributing toresistance (Laxminarayan et al. 2013), leading to health crises arising from infectionsthat were once easy to treat (Hay et al. 2018). In high-income countries, patientswith resistant infections frequently have the opportunity to turn to newer-generationantibiotics, which are more expensive. In low-income countries, where infectiousdiseases are leading to a high disease burden, patients might be unable to obtain orto afford second-line treatments (Laxminarayan et al. 2013). Infections resistant toantimicrobial treatment frequently result in longer hospital stays, higher healthcareexpenses, and increased mortality (Hay et al. 2018).To combat antimicrobial resistance, comprehensive national and internationalplans, like the Antibiotic Stewardship programme in the European Union (Allerbergeret al. 2009), are needed to allow for rationale antibiotic use in hospitals (Laxminarayanet al. 2013). Furthermore, due to the connection between antimicrobial resistancesand the agricultural sector, the One Health approach comes into play. The One Healthapproach supports global health security by improving coordination, collaborationand communication at the human-animal-environment interface. For doing so,multiple disciplines working locally, nationally, and globally are included, to addressshared health threats such as zoonotic diseases, antimicrobial resistance, food safetyand others (American Veterinary Medical Association 2008; Sinclair 2019).1204.2. Climate ChangeThe 2019 report of The Lancet Countdown on health and climate changeemphasised that the health of a child born today will be affected by climatechange over its whole lifespan (Watts et al. 2019). Therefore, climate change isan emerging threat to global health, as it has myriad implications for the health ofhumans and the ecosystems (Machalaba et al. 2015; Patz et al. 2014). The effects ofclimate change are closely linked to social and ecological determinants of diseasemitigating or exacerbating forecasted adverse health outcomes (Machalaba et al.2015). Climate change is also highly inequitable, as the greatest risks are to thepoorest populations, who have contributed least to greenhouse gas emissions(Campbell-Lendrum and Corvalán 2007). There is a substantial overlap betweenunderlying determinants of health inequity and environmental change. Friel et al.(2008) claimed that they “are signs of an economic system predicated on asymmetricgrowth and competition, shaped by market forces that mostly disregard healthand environmental consequences rather than by values of fairness and support”.For that reason, multidisciplinary collaboration and a shift in priorities in economicdevelopment towards healthy forms of urbanisation and infrastructure, more efficientand renewable energy sources, and a sustainable and fairer food system is needed(Friel et al. 2008). Without immediate actions, climate change will impact on thehealth of current and future generations, will pose challenges to already overwhelmedhealth systems, and will undermine the progress towards achieving the SDGs anduniversal health coverage (Watts et al. 2019).4.3. MigrationGlobalisation is characterised by increases in population movement.International migration is a complex phenomenon affecting a multiplicity of economic,social and security aspects. However, with about 250 million international migrants in2015, and a projection of more than 400 million in 2050 (IOM 2018), and significantlymore people moving within their country of birth, there is an urgent need toengage with the topic of migration in global health (Wickramage et al. 2018).Therefore, the UCL-Lancet Commission on Migration and Health called on “nationstates, multilateral agencies, non-governmental organisations, and civil society topositively and effectively address the health of migrants by improving leadershipand accountability” (Abubakar et al. 2018). Despite the human right to health,national sovereignty concerns frequently overshadow legal norms, as attention tomigration focuses largely on security concerns (Abubakar et al. 2018). This hasbeen highly visible at the so-called “refugee crisis” impacting Europe in 2015/2016,121which was much more a “crisis of solidarity” (Bozorgmehr and Wahedi 2017).In this regard, fundamental human rights have been restricted to asylum seekersin many recipient countries, because access to adequate healthcare was denied(Bozorgmehr and Razum 2016).In the context of global health, it is mandatory to consider the “Health in allpolicies” approach, because the steady increase in international migration has ledto hostile migration policies worldwide, such as expanded border controls in theEuropean Union and attempts to rescind legal protection granted to undocumentedmigrants in the United States. All these policies have not been designed to negativelyaffect migrant’s health, but their role as social or political determinants of health isundisputable (Juárez et al. 2019).4.4. DigitalisationDigitalisation, one of the megatrends of our time, is of particular relevance forglobal health. First of all, it affects our lives like nearly no other societal, technologicalor economic development. Second, digitalisation is global itself. In developedand developing countries alike, modern communications technology is no longera convenience—it is a necessity. Due to its importance, the increase in access toinformation and communication technologies is addressed in SDG target 9c. Digitalstrategies have been recognised as a critical strategy for health systems strengtheningto help meet the SDGs and universal health coverage targets (Labrique et al. 2018).Digitalisation is crucial for precision global health, which is describes as an approachsimilar to precision medicine. Through innovation and technology, it facilitatesbetter targeting—or even tailoring—of public health interventions on a global scale(Flahault et al. 2017). For that reason, digitalisation brings new potential for globalhealth, but further reflections on its ethical implications and social impacts are needed(Dockweiler and Fischer 2019).5. ConclusionsNever before has global change happened so quickly. The societal,epidemiological and demographic changes we face require new and particularlyglobal strategies to gain the common goal of universal health coverage. Global healthis closely linked to sustainable actions. Indeed, global health actions need to besustainable to improve the world population’s health in the long term and to reducehealth inequities.122All global health actions should be based on the best available scientific evidence.Therefore, Rudan and Sridhar (2016) summarised the “basic needs” of the globalhealth research system that emerged from the past:• coordination of funding;• prioritisation of the plentiful research ideas;• recognition of results of successful research;• broad and rapid dissemination of results and their accessibility;• evaluation of return on investments.Best practice examples could serve as prototypes for a better coordination andorganisation for the common goal of a higher standard in public and global healthwithout causing substantial or additional costs for research, development and design(Rudan and Sridhar 2016).Until the recent past, the European Union for example defined global healthmainly in terms of strengthening “global and third countries’ national capacitiesof early prediction, detection and response to global health threats” (EuropeanCommission 2010) rather than focusing on cross-border health threats. Germanyused its presidencies of the G7 and G20 summits in 2015 and 2017 to give moreprominence to global health in supranational political discussion (Berner-Rodoredaet al. 2019). However, the focus has been relatively narrow. Therefore, McBride et al.(2019) recommended expanding the focus to neglected SDG3 health targets to placegreater emphasis on upstream determinants of health, provide stronger commitmentto equity and leaving no-one behind, adopt explicit commitment to rights-basedapproaches, and make commitments that are of higher quality and which includetime-bound quantitative targets and clear accountability mechanisms.Reaching SDG 3 targets is undeniably an enormous challenge that comes alongwith structural and financial demands, which are compounded by additional hazards,such as political conflicts, natural disasters and famines, but also new global problems,for example antibiotic resistances and the adverse health effects causes by climatechange. Therefore, sustainable development needs to be at the core of the globalagenda (Kickbusch 2014), allowing for a long-term implementation of public healthinfrastructure, is needed to accomplish SDG 3. Action on the social determinantsof health—based on a “Health in all policies” approach—is required to reduceinequities in health (Donkin et al. 2018). Accountability, vested interests, ethics anddemocratic legitimacy are conditional for future sustainability of population health(Byskov et al. 2019).The overall changes in the past years, in terms of the increasingly globalisednature of economy, society and culture, combined with, e.g., the effects of climate123change and environmental degradation as well as the evolution of antibiotic resistance,have led to shift the boundaries. These factors expose both new and forgottensimilarities between populations. Furthermore, they highlight the need for globalcooperative responses to health threats. Therefore, the grand challenges can serveas “a catalyst for global solidarity, which justifies, and provides motivation for, theestablishment of solidaristic, cooperative global health infrastructures” (West-Oramand Buyx 2017, p. 212).Reaching the goal of a better health and universal health coverage also implieschanges in other areas than health and, thus, addresses more SDGs than just SDG3. Therefore, integration of global health concerns into the law and governance ofother, related disciplines should be given high priority. This emphasises the needfor developing and implementing a “global health” policy, and not only a global“health policy”.Author Contributions: Both authors jointly conceptualised and wrote this contribution.Funding: This research received no external funding.Conflicts of Interest: The authors declare no conflict of interest.ReferencesAbubakar, Ibrahim, Robert W. Aldridge, Delan Devakumar, Miriam Orcutt, Rachel Burns,Mauricio L. Barreto, Poonam Dhavan, Fouad M. 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Towards Sustainable Digitalized HealthcareDigitalization in the health sector is, as in all societal domains, motivated bya range of anticipated positive consequences, such as increased effectiveness ofprevention, treatment and follow-up, a generally improved resource efficiency andimproved health care availability. This chapter will discuss how the ambition ofachieving sustainable health goals may be affected by measures of digitalization. Thiswill be done by covering digitalization from a cyber security perspective and hownew potential threats to privacy may influence the public’s trust in their health caresystem, thereby affecting the envisaged goals of sustainable health care performance.It will also discuss further how digitalization in the healthcare sector unleashes anenormous potential in terms of cost-effectiveness, decentralization and the availabilityof specialist services and expertise, which risks and countermeasures these changesentail, and how they are currently dealt with and the role of cyber resilience inensuring rapid digitalization does not come at the cost of essential trust mechanismsthat are quid pro quo in the health sector.Transformation to a digitalized healthcare system must be governed and framedby a range of measures in various societal domains. The World Health Organization’s(WHO) report on the status of eHealth in the European region (WHO 2016) states thatits member states “acknowledge and understand the role of e-Health in contributingto the achievement of universal health coverage and have a clear recognition ofthe need for national policies strategies and governance to ensure the progress andlong-term sustainability of investments. However, leveraging eHealth as a nationalstrategic asset demands a more coordinated approach [ . . . ]” (WHO 2016, p. xi).The WHO acknowledges the fact that a majority of its member states developed orare developing “national strategies or policies for eHealth, universal health coverageor national health information systems, and ensuring sustainable funding for theirimplementation.” (WHO 2016, p. xi). The report requests the member states todevelop an “inclusive and intersectorial approach to the development of national133eHealth strategies” (p. xii). These international efforts to adapt to the consequencesof technological development provide an example for the wide ranging consequencesthat the digitalization of health systems entails for legal security measures relatingto a state’s power over its citizens, institutional development, policy and practice,education, and cyber security. We argue that cyber security, in turn, is not just one ofmany subjects to consider, but instead it pertains to and penetrates all other affecteddomains, such as the aforementioned organizational structures, policymaking, andeducation of non-technical healthcare professionals, as well as legal structures.The healthcare system’s efficiency and effectiveness depends on policies andprocedures such as the rapid and precise exchange of health-related informationbetween its different acteurs. In recent years, more national healthcare systemsapproached sustainable health benefits for their populations by digitizing theirservices and administrative procedures, enabling new innovative models of healthcare delivery and efficient data sharing amongst stakeholders. Digitalization on asystem level led to increasingly centralized databases offering synergies for newresearch possibilities, and the opportunity to improve individualised, time- andcost-efficient healthcare covering hitherto underserviced areas, such as disadvantagedparts of society or structurally weak geographical spheres. The manifold effects ofdigitalized healthcare result from a large variety of technological innovations onindividual, institutional or system level.The concept of e-Health combines aspects of areas such as healthcare businessand administration, public health, and medical informatics. This broad term coversaspects of healthcare delivery, data administration and relies, to a large extent, on theavailability of web-based patient care via communication platforms. e-Health is botha technical tool of practical healthcare delivery as well as a governance instrument.The term is also used as a more general description of a larger variety of digitalizedhealthcare. On the contrary, the term m-health (“mobile health”) is a particularaspect of e-health describing medical and public health practice via mobile (wireless)electronic devices such as smartphones or specific monitoring devices such as EKGmonitors or glucometers. Telehealth is a rather broad term referring to remote clinicalservices, as well as non-clinical activities such as training and medical education.The narrower term telemedicine is the aspect of telehealth dealing with remoteclinical services. These various manifestations of digitalized healthcare contributeto the gradual achievement of sustainability goals in a number of ways. Within thelast ten to fifteen years, electronic health records have become a universal feature ofdigitalized healthcare. This increased availability of digitalized information and theoverall improved information management by healthcare professionals accelerated134decision-making time, provided an information basis for better outcomes of clinicaldecisions, facilitated interdisciplinary cooperation, reduced the fragmentation ofinformation between healthcare providers, and reduced duplicate tests and othertreatment risks or side effects (Atasoy et al. 2019).In developing countries, digitalization and thus this universally availableinformation has increasingly been used not only to process patient-related information,but also to make medical services and the competence of rare and remote healthcare providers accessible to rural and secluded regions with lacking or insufficientmedical infrastructure (Zhang and Zaman 2019) by means of eHealth. While eHealthhas been mostly seen in terms of reducing inequality to access of healthcare, adiscussion on unequal access to these benefits emerges. As mHealth contributesto an increased autonomy and strengthening of the patient role as administratorand gatekeeper over own health-related data, this increases the demands towardspatients considerably. The access to “patient-facing” mHealth and a consequentlymore responsible and autonomous patient role are raising concerns related to digitalinequality and cognitive skills. Unequal access to the benefits of digitalization fordeprived societal groups could be particularly pronounced in countries with ratherlimited universal healthcare, such as the USA or developing countries.2. Digitalization and Increased VulnerabilityHighly digitized healthcare systems relying on electronic health records are avital part of a nation’s critical infrastructure. Critical infrastructure describes the“physical and cyber systems and assets that are so vital [ . . . ] that their capacity ordestruction would have a debilitating impact on [ . . . ] physical or economic securityor public health or safety” (Department of Homeland Security 2019).The model of an increasingly patient-centered healthcare emphasizing theindividual’s needs, rights, autonomy, preferences and values guiding all medicaldecisions is increasingly promoted and spread as a development unfolding parallelto digital change. Healthcare systems involve patients to an increased extent inambulatory data collection, provide more insight into patient documentation, securethe patient’s rights to own the data and become more inclusive when choosingamongst treatment options. As an effect of the increased cooperation between patientand numerous other acteurs in the healthcare system, the increased amount ofpatient-centered sensitive data is bundled, stored and processed in centralized orhighly interconnected digital infrastructures.The amount and availability of patient-related data are tempting high-valueassets for criminal undertakings. The extent to which the healthcare sector has135become a primary target of cyber crime is reflected in the number of cyber attacks onhospitals in recent years. More than 2000 breaches involving a total of 176 millionpatient records were reported between 2010 and 2017, with individual breachesranging from 500 to nearly 79 million patient records. The total number of breachesincreased from 199 in 2010 to 344 in 2017 (e.g., McCoy and Perlis 2018). One ofthe first occasions when the international general public became aware of cyberattacks on the health care sector was the 2017 WannaCry ransomware attack infectingan estimated 230,000 windows systems in 150 countries (Chen and Bridges 2017).The unprecedented scale of this cyber attack brought the relatively neglected field ofcyber security in the healthcare sector onto the agenda of media, healthcare providersand policy makers.The many years of negligence towards cyber security made many healthcareproviders particularly easy targets, especially when compared to highly protectedsocietal domains such as the military, law enforcement, and innovation-driveneconomy safeguarding their intellectual property or high-value tactical or strategicdecisions. The Norwegian data breach of 2018 is a particular—but notexclusive—example of a targeted attack with the criminal intent to obtain sensitivepatient data exploiting the lack of awareness and preparedness. The targeted attackresulted in the extraction of 2.9 million datasets, including patient records, resemblingmore than half of Norway’s population (Hughes 2018; Johansson 2018). The attackis believed to have been carried out by highly sophisticated attackers explicitlytargeting patient records stored by the health authorities in the South-East regionof Norway. Following further investigations, it was assumed that the attackerswere focused on the health service’s relationship with Norway’s armed forces andpotential information regarding a major NATO exercise organized in Norway later inthe year. The cyber attack seems to have benefitted from lax security standards andoutdated operating systems no longer supported by security updates. Accordingto the investigations of a national newspaper, as late as in 2017, about 1200 ofthe Health-South-East’s computers were still running on Windows XP, about threeyears after Microsoft ceased supporting the popular operating system (Irwin 2018;VG 2017).While these events demonstrate clearly the need for heightened cyber securityawareness and preparedness, the viciousness of criminal hackers—be they roguecriminals with economic interests, financed by nation-states, competitors orothers—data breaches do not necessarily presuppose criminal intent. Humanfailure is known to be the major vulnerability of all technical systems with whichhumans interact (“socio-technical systems”). Human failure provides numerous136“attack vectors”, i.e., opportunities to exploit a person’s individual vulnerability inorder to access a targeted network. However, while processes, people and technologyneed to be designed, trained, and maintained in a way that reduces the risk ofhuman failure enabling third parties with malicious intent to get access to sensitivedata, the loss of sensitive patient data does not necessarily require malicious intent.Amongst some of the most prominent—known—health data breaches made publicin recent years include the breach of data on 150,000 patients by the UK’s NationalHealth Service being shared without their permission in 2018. In fact, the patientswhose data were made public actively opted out of any use of their data beyondown treatment. The breach was later explained as a “coding error”, i.e., an internalhuman failure without any criminal intent (Canham et al. 2020). The National HealthService (NHS) data breach of 2018 indicates how cyber security breaches and effortsto improve information security management routines are of crucial relevance forthe patients’ trust in the healthcare system, even in the absence of any criminalattempt, as it undermines the public trust in the institutions’ very ability to maintainsecure information processing as a part of their daily routines, and in the absenceof acute threats. The case of the NHS data breach demonstrated impressively howa digitalized data administration potentiates the detrimental impact of singularhuman failure.The motivation for targeting the health sector is comparable to other large societalsectors such as public authorities, governmental or non-governmental organizationsor industry. With cybercrime dominating, hacktivism and cyber espionage arethe major motivations behind cyber attacks in the healthcare sector (Passeri 2017).The often-reported observation that human factors seem to play a particular role incyber breaches targeting the healthcare sector, has been associated with the particularlack of security awareness, training, and security-related attitudes (Kim 2017). As aresult, health and hospital trusts are frequently considered “low hanging fruits” bycyber criminals aiming for financial profits on the black market for patient data.In addition, and in the comparably smaller but potentially more devastating caseof nation-actors, the healthcare sector provides a relatively easy entrance for theacquisition of sensitive information required to paralyze a potential enemy’s criticalhealthcare infrastructure in a conflict situation.Cyber security rests upon three pillars; confidentiality, availability, and integrity(Conrad et al. 2012; Canham et al. 2018). Cyber-attacks focused on the confidentialitypillar expose private information (such as credit card or health information) tounauthorized persons. The American Medical Collection Agency (AMCA) databreach in which 12 million patient records were exposed is an example of an attack137using the confidentiality pillar. The integrity pillar represents the prevention ofunauthorized modification of a system or data. Attacks against the integrity pillarmodify data in such a way that it becomes untrustworthy, and the attack maynot be discovered even after the damage has been done. In a healthcare context,cyber threat actors who attack the integrity pillar might change a patient’s dosageinstructions and create a potentially unsafe situation for that patient. The Stuxnetworm is often cited as an example of an attack on information integrity that caused alarge number of Iranian uranium centrifuges to malfunction. This attack employedmalware specifically designed to provide false performance readings to operatorsthat left them unaware of an impending problem (Chien et al. 2012). Securityresearchers have conducted proof-of-concept attacks against the Integrity Pillar ofneuro-prosthetic devices and were able to inject commands that disrupted the device’snormal functionality (Canham and Sawyer 2019; Cusack et al. 2017). The availabilitypillar focuses on information assurance; in other words, ensuring that users are ableto access the data that they are authorized to access. Examples of attacks against theavailability pillar include the multitude of ransomware attacks against hospitals andhealthcare facilities over the past few years.The examples of major data breaches provided above are only a very small partof the overall picture and do by no means cover a substantial part of known cyberthreats. Commercial cyber security providers publish regular lists of conducted cyberattacks that have become known. At the time point of detection, cyber attacks haveusually already happened, and a considerable number of attacks and conducted dataextractions may remain undetected or unreported. The majority of attacks directlytarget individual hospitals as key centers of gravity, with direct access to patients’sensitive data, while being known to be lagging far behind other institutions ofcomparable size in terms of their cyber security standards. Where a few hospitalswith low resources for cyber security threaten the entire infrastructure due to theirinterconnectedness, the efforts to become a less attractive goal for cyber criminalsneeds to step up considerably. These efforts need to go beyond current regulationswhich largely focus on questions related to data privacy, but not data security(Jalali and Kaiser 2018). A surge in related analyses and systematic research onrisk factors and potential countermeasures in recent years indicates an increasingawareness amongst the stakeholders, which may lead to increased future investmentin technology, processes and personnel (Coventry and Branley 2018; Kruse et al. 2017;Martin et al. 2017).1383. Improving Sustainable Healthcare and Ensuring Cybersecurity:The Estonian CaseAs digitalization as a means to improve national healthcare systems’ effectivenessand efficiency comes with increased data exchange accompanied by an increasedpotential of vulnerabilities towards security threats, governments work towardsfinding a balance between technically feasible solutions maximizing the outcomebenefits, whilst minimizing the threat potential with cyber security measures. Cyberresilient healthcare systems contribute to and maintain public acceptance for furthertransformation and sustainable development initiatives, and bolster public perceptionof information security. When discussing these future trends, the digitalization ofthe Estonian healthcare system may serve as a blueprint for future developments inother countries, too. The Baltic country with approximately 1.2 million inhabitants isconsidered a world leader in both e-government as well as cyber security. Estonia isregarded to be one of the most digitized countries of the world and has firsthandexperience of being subject to hostile cyber attacks by a foreign state power. In 2007,a Russian cyber attack brought the Estonian public authorities, organizations, mediaand with it, the usual public life, to an abrupt hold. The attacks were interpreted asan expression of Russia’s disagreement with the relocation of a Sovjet-era bronzesoldier statue in the capital city Tallinn. In the aftermath of these attacks andreinforced by a continuously perceived threat by Russian interference, the countrypublicly and privately invested heavily in cyber security infrastructure, processesand competences. Both the level of digitalization of the country’s healthcare servicesand the technological advancements in cyber security make Estonia an interestingcase study and “laboratory” providing possible insights into future developmentson an international scale. Trends and consequences in Estonia are likely to be—insimilar or partial form—also introduced in other countries.Estonia’s healthcare system’s patients and doctors, hospitals and the government,have to rely on e-services for health. Each person in Estonia that has visited a doctor atleast once has an online e-Health record. The core of the Estonian e-Health System isthe digital health record that functions as a centralized, national database and retrievesdata as necessary from various providers, who may be using different systems, andpresents it in a standard format via the e-Patient portal (e-estonia.com). Thesee-Health records are, among other purposes, used for prescriptions and in emergencysituations. E-ambulances are available in emergency situations to detect and locatean emergency call within 30 seconds. On board the e-ambulance, a doctor can usea patient’s ID code to read time-critical information, such as blood type, allergies,or recent treatments. To balance these obvious advantages in availability, efficiency139and cost-effectiveness on the societal level, data privacy for the individual is securedby various means. Sensitive patient information is only accessible by authorisedindividuals identified via national electronic ID cards. Highly secure state-of-theart data transmission encryption techniques (Keyless Signature Infrastructure (KSI)Blockchain technology) are used for the system to ensure data integrity and mitigateinternal threats to the data. Data transport and security layers are provided for by thegovernment’s data transmission software (“X-Road”), ensuring that only digitallysigned and encrypted data are exchanged (Priisalu and Ottis 2017). The electronicdatabases are organised in a decentralized manner ensuring that cyber attacks or leakscannot compromise the overall system. There are no so-called super-administratorswith unrestricted access to patients’ health records (Health and Welfare InformationSystems Centre (TEHIK) (2019)). By default, medical specialists can access datausing their unique individual identifier, but any patient can choose to deny accessto any case-related data, to any, or all care providers; including one’s own generalpractitioner (Priisalu and Ottis 2017). Every patient thus keeps full autonomic controlover the stored data, provides permission and keeps the full overview over whichindividual person has accessed their personal information. Each data view leaves anidentifiable trace and record.The privacy and processing of personal data processed in the Estonian healthcaresystem and other public databases is regulated by the country’s Personal DataProtection Act and the European Union’s General Data Protection Regulation(GDPR). The governing principle is to provide an open and transparent attitudeas a prerequisite for a robust trusted relationship between the citizens and thestate. By investing in a person’s confidence in the government’s ability to keeptheir data secure and guarantee confidentiality, integrity and availability. Whilethere are no direct survey data describing the public and individual trust into theEstonian eHealth services available, the high rate of access and usage since thesystem’s introduction in December 2008, the constantly high ratings of perceivedquality of healthcare in public surveys indicate a level of acceptance (Lai et al. 2013).The Estonian example combines state-of-the art e-government services with newestcyber security technology, maximizing the potential of “security by design”, i.e.,providing technology with least possible vulnerabilities and robustness towardshuman failure. To ensure public acceptance and trust, the patient is given fullautonomy and transparency over the use of his/her personal information.There are currently no known comprehensive data breaches following attackson the Estonian healthcare system. While security-by-design solutions are a powerfuland necessary means to provide cyber resilience, the human factor remains a140considerable risk factor, particularly in less advanced partially digitalized systemsand healthcare systems with lower degrees of centralization, as typical in largercountries. Human behaviour thus remains a constant threat of cyber security that issubject to intensifying research efforts by behavioural and interdisciplinary scientists.4. The Human Factor in the Healthcare System’s Cyber SecurityResearch on the human factor in cyber security acknowledges that technologydoes not exist in isolation, but that interpretations, conclusions and decisions aremade by individuals or groups of humans with the “inbuilt guarantee” to commit awhole range of human failures if given the opportunity. Thus, even the best designedsystem for processing and storing sensitive data in a healthcare system faces humanusers and thus human failures, which potentially compromise data security at leaston an individual, if not even systemic level, in unforeseen ways. These humanfailures—such as the coding error enabling the 2018 NHS data breach—occur onindividual levels following erroneous conclusions and decision-making processes,insufficient or biased information as a decision-making foundation followinginappropriate or inaccurate communication between individuals, teams, institutionsor authorities. Given the relatively recent awakening concerning awareness of cybervulnerabilities in the healthcare sectors, we argue that the human factor based ontraining, education and compliance, is of particular importance. In areas such asaviation, acute medical care, and many safety- and security-critical sectors, thedevastating effects of human failure, for example by miscommunications, are welldocumented and acknowledged. In the area of cyber security, knowledge about thesources and underlying reasons of human failure and performance is still relativelyscarce and “work in progress”, but the amount of systematic research in this field isgrowing (Sütterlin et al. 2019).Amongst the various ways in which human failure occurs and threatens cybersecurity, procedural compliance is one. A lack of procedural compliance whentechnology users do not adhere to existing security protocols can result from suchprotocols being too complicated, formulated in a, not understandable way, and highlytechnical. Other factors include the failure of organizational cultures, where enforcedhierarchies and authoritarian leadership styles foster a culture of low tolerance tocriticism and constructive feedback upwards along the vertical axis, making availablecompetencies of lower ranking and technologically savvy younger experts unavailablefor strategic decisions (Jøsok et al. 2016). Communicative challenges betweenindividuals, teams, organisations and sectors particularly in interdisciplinary groupsset up in an ad hoc manner and without established collaborative routines provide an141environment that is particularly prone to misunderstandings, misinterpretations, andthe loss of relevant information, resulting in discrepant mental models of a cyber threatsituation. The reason why cyber security is particularly vulnerable to communicativechallenges is the highly technical nature of the threat. A profound understandingand interpretation of a technical situation, its real-life consequences, options to actand their various anticipated consequences and associated risks in a cyber threat orcyber incident situation, with high stakes, that is potentially also characterized bytime pressure and based on ambiguous information, creates an enormous cognitiveindividual and organizational workload prone to human errors. The creation of ashared situational awareness between technicians, decision-makers, and all otherstakeholders requires a high degree of technical specialization in combination withefficient communication routines across disciplines, departments, organisationsand societal sectors. The availability of understandable, yet accurate, technicalinformation providing this shared situational awareness and decision-making abilitygives technologically less informed decision-makers the ability to react and act withappropriate tactical and strategic decisions. The challenge is to provide an accurateyet simplified description of a given threat situation. The consequential options toact as well as the probabilities of anticipated consequences pose particular challengesin a context where not the shortage of information, but the overwhelming availabilityof it, adds to an enormous cognitive load for all stakeholders. In the communicationof cyber threats, it is therefore not the situational status per se, but the outcome of itsperception, interpretation, and communication by the cyber security technician thatshapes the decision-makers’ experienced reality. The decision-maker on the receivingend depends upon their understanding and thus upon the technician’s simplification,selection, weighting, and interpretation. Knox et al. (2018) described the conditionsthat need to be put in place to facilitate information exchange on recognized cyberpictures between individuals and propose an orient-locate-bridge-model (OLB)describing how institutions can apply educational methods to enable both their cybersecurity personnel as well as their leaders in the effective communication of cybersecurity related situations (Knox et al. 2018).Lacking procedural compliance and ineffective communication only representexamples of a number of ways in which human failures affect cyber security in andbeyond the healthcare system. While there is a lack of research on human factor-relatedcyber security risks in the healthcare sector, the more extensive human-factor relatedknowledge from other domains can be transferred and applied in the healthcaresector as well. Human factor research can contribute to risk identification and thedevelopment of training approaches to facilitate cyber resilience. With 94% of malware142distributed via email in 2018 (Verizon Communications Inc. 2019), phishing mails arethe tool of choice to breach targeted networks. Empirical research has identified fourcategories of risk factors for susceptibility to phishing mails. These are situationalfactors, social engineering techniques, cultural factors, and individual differences(Canham et al. 2019). Employees who might not, under “normal” circumstances,be susceptible to a phishing attacks may be susceptible when distracted, or undersignificant cognitive load; in this way, situational factors play a major role insusceptibility. The social engineering techniques employed by threat actors can bevery sophisticated and even appear to originate from known contacts. Some researchsuggests that cultural influences along the individualism–collectivism spectrum maysignificantly contribute to susceptibility (Butavicius et al. 2016). Finally, individualdifferences relating to personality and propensity to trust appear to account for someusers being more susceptible than others. The most vulnerable users, sometimesreferred to as “repeat clickers”, represent a small minority of users who repeatedly fallprey to simulated phishing campaigns meant as training exercises. While these usersusually only account for one to two percent of users within an organization, they canrepresent nearly 50% of the total simulated phishing failures (Canham et al. 2019).Health care workers seem to fulfill some of these criteria, as they have showna high propensity to click on phishing scams and have limited awareness ofthreats (Priestman et al. 2019). In a sector where women make up over 70% ofworkers in the health sector (WHO 2019) and usually rank higher on traits such asneuroticism, agreeableness (Parrish et al. 2009; Weisberg et al. 2011) and reward-baseddecision-making, known risk factors for maladaptive cyber behaviours cumulate.Getting targeted training to health care workers is essential in establishing andmaintaining cyber resilience on an organisational level (Ghernaouti-Helie 2013).Other influencing factors determining susceptibility to fraudulent emails servingas an attack strategy to achieve entrance into sensitive IT systems are personalityfactors. IT users who are agreeable, emotionally less stable, and technically lessknowledgeable, show higher risks of all unintended security violations in phishingattacks (Gratian et al. 2018; Halevi et al. 2013).These vulnerabilities are usually addressed in cyber security education andtraining programmes. While these trainings are by far not sufficiently available andwidespread in the healthcare sector, they are not even suitable to address all sourcesof errors. Even though general security training has shown to increase pro-securitybehaviors to some extent (Darwish et al. 2012), more targeted education is requiredto reach a significant improvement and lasting effects on behaviour.143In 2018, the United Kingdom’s Information Commissioner (ICO) commissionedKroll to conduct a study of all data breaches experienced by the UK governmentin 2017, 2124 incidents in total (Targett 2018). This study found that 88% of alldata breaches involving UK government entities resulted from unintentional humanerror, without the direct involvement of a cyber threat actor. Examples of theseerrors included emailing unencrypted confidential patient information to the wrongrecipient (21%), loss or theft of paperwork (20%) and data left in an insecure location(7%). Of the reported malicious cyber breaches, unauthorised access was the mostcommon, accounting for 4% of the total, followed by malware (2.5%), phishing attacks(2.4%) and ransomware (1.5%). The healthcare sector accounted for the majority(57%) of these breaches, followed by general business (17%), education and childcare(16.7%), and local government (15.4%).Knowledge workers in the information economy are often overworked, facingstaffing shortages and constant deadlines. These workers commonly experience atension between complying with security policy friction and accomplishing assignedtasks within deadlines (Posey and Canham 2018). Workers in the health care sectorare no exception to this situation. One of the leading causes of (or contributing factorsto) human error, is time pressure. Time pressure manifests in errors in two primaryways, deliberate policy violations and unintentional human errors (Reason 1990;Norman 2013).The two categories of deliberate policy violations are routine violations andsituational violations. Routine violations occur when policy non-compliance is socommon that it is mostly ignored. A frequent example of this is the emergence of“shadow IT” systems. Shadow IT systems represent workarounds that users adoptin order to complete their work in an easier (but often less secure) manner. Examplesinclude using unauthorized external cloud services or installing unauthorizedwireless networks in secured spaces. Situational violations occur during exceptionalcircumstances. For example, in order to save a patient’s life, emergency departmentmedical staff might leave a proximity card on a monitoring cart in order to prevent thelock screen from activating. These violations are not routine, and usually occur whenthe cost of following proper security procedures is higher than abiding by them. Bothroutine and situational deliberate policy violations should give security staff pause, toreflect on the appropriateness of the policies causing these circumstances. If a policyis so cumbersome as to lead to it being deliberately ignored, this may be a good areato explore policy alternatives as a way to encourage secure behaviors. If existing ITinfrastructure is so cumbersome to use that users are leveraging external resources,perhaps the existing infrastructure can be made more user friendly. Devices that144utilize timeout lock screens might be modified to include an “emergency mode” sothat they will not lock for the duration of the emergency.Human errors, in contrast to deliberate violations, are unintentional and usuallyresult from two distinctly different sources. The first type of human error is knownas slips. Slips occur when an individual intends for one action to occur, but insteadexecutes a different action. In this case, the person understands the correct actionto take, but inadvertently takes the wrong action. An example of a slip might bepouring milk into coffee, but then placing the coffee cup in the refrigerator instead ofreplacing the milk (Norman 2013). In a cyber context, email address auto-complete islikely responsible for a great number of slip errors. Recall that the Kroll study foundthat emailing unencrypted confidential patient information to the wrong recipientwas responsible for 21% of the 2017 data breaches (the largest number). In contrast toslips, mistakes are another type of human error that occur when an individual hasthe wrong goal (Norman 2013). Humans form mental models for how tools, artifacts,and environment operate and interact (Johnson-Laird 1983). These mental modelsencapsulate a simplified mental representation that allows the human mind to makepredictions for actions taken with the things we interact with. Unfortunately, thesemental representations are not always correct. When they are incorrect, this oftenleads to the wrong goal being formed, and an error then usually occurs. If a userbelieves that their employer has stronger security than what they have at home, theymight forward a questionable email that they receive at their personal email account,to their work account, with the belief that the organization’s security resources arebetter equipped to manage malicious software than their home system is. If this werethe case, then this person would be taking the correct action, but of course this isfalse and based on an incorrect mental model.This distinction between error types comes with consequence. In the cybersecurity industry, much emphasis is placed on user awareness training, with theimplication being that if users were simply more aware of the inherent risks associatedwith their actions, they would be less vulnerable to attacks or committing errorsleading to breaches (Carpenter 2019). While this may be true in some cases such asmistake type errors, it is untrue with regard to slip type errors. Slip errors result fromhighly learned behaviors that have become automatic and usually occur withoutconscious processing. In fact, slip errors tend to be more common in expert users,because they are so familiar with these actions. No amount of awareness trainingwill fix slip errors; the best method to deal with these will likely be better design ofinterfaces and processes. Mistake errors result from incorrect goals, usually derivedfrom incorrect mental models. Mental models can be updated through training145and, therefore, these types of errors might be corrected through awareness training.Because these policy deviations can have radically different causes, they need to beaddressed through different means (Canham et al. 2020). Security personnel in thehealth sector would be served well to track these errors in relation to data breachesand security violations and use these as a guide for developing corrective actions.5. Cyber Resilience and TrustIn the previous sections, we laid out how digitalization transformed the wayhealthcare systems perform and the benefits these changes entail, as well as thevulnerabilities that come with large-scale health data administration. We alsoprovided examples of how human behaviour can pose a large risk for breaches ofsensitive data. Cyber resilience is more than the prevention of valuable data beingstolen or the direct and collateral damages associated with a cyber attack. While datacan in many cases be restored by backups, malware isolated and eliminated, andaccess to blocked data can be regained (ransomware)—there is a wider picture to it.Stolen data or access credentials and system vulnerabilities can spread in uncontrolledmanners and be sold on illegal markets. The whereabouts of breached data remainusually unknown for long time periods, occasionally for years. The perpetratorscan, in most cases, not be clearly identified, which adds an additional componentof insecurity for the victims of cyber attacks, widely known as the “attributionproblem”. Cyber threats in the healthcare sector can have acute detrimental effectsin times of national crisis (functionality of the healthcare system), hybrid warfare,or international conflicts above or below the threshold of war. In peacetime and inwestern democracies, however, breaches of data that were administered by private orpublic bodies (healthcare providers, insurances, etc.) can also undermine the publictrust in these institutions. Public awareness and scepticism therefore influence policiesaround the digitalization of healthcare and consequently affects the development ofinstitutions at the frontline of healthcare and achievement of sustainable developmentgoals. The crucial role of people’s trust in the protection of their privacy and thus inthe integrity of the healthcare system as a whole has been recognized by state actorsand lead to the development of relevant legal frameworks facilitating privacy, securityand thus overall cyber resilience as a prerequisite of trust in a sustainable healthcare.According to the World Health Organization, trust in privacy legislation is key for thepopulation’s “confidence in their national eHealth programme” (WHO 2016, p. 77).To reach a sufficient level of cyber resilience allowing for the further development,implementation and maintenance of digital solutions in healthcare, the vast majorityof industrialized countries have established national legislation regulating the sharing,146storing and use of personal data and/or personal health-related information as well asinformation exchange. While these legal frameworks have been put in place, the lackof cyber resilience on institutional levels makes healthcare institutions still an easyprey for malicious attacks or human failures due to mistakes and behavioural slips.One such cognitive barrier to prioritising cyber-resilience is the cost of investing inmanaging something that steals time from the primary and measurable role of theinstitution (Elgsaas and Heireng 2014). Investing time and resources into cyber securesystems and the people capable of ensuring persistent network resilience comes atconsiderable costs and is only rarely seen as a necessary and important investmentin value generation (Coventry and Branley 2018). This is especially so when futurefunding for health institutions is very often performance related. Unfortunately,performance of cyber and information security is not the key criteria, meaning thatin many countries, speed and efficiency of digital systems is prioritised ahead ofsecurity and resilience. For this reason, the introduction and implementation ofdigital systems in healthcare with the security by design principle at the forefront ofdevelopment, and meet certain recognized classification frames, should be a step inadding cyber resilience from the start.In Europe, national legal frameworks are directly affected by supernationallegislation. The European Union Cyber Security Act of 2019 aims to increase EUresilience and response to cyber-attacks. The act established an EU framework forcybersecurity certification aimed at boosting the cybersecurity of digital productsand services in Europe, including the various national healthcare sectors. In practice,the certification framework means improved cybersecurity across a wide spectrumof existing digital products and services, including the Internet of Things, as well ascritical infrastructure such as, for example, hospitals. Even though these measures arenot specifically aimed at cyber resilience in the healthcare sector, it contributes to theharmonization of cybersecurity standards, increasing the effectiveness in respondingto cyberattacks as the system or device has a familiarity to it based on it meetingprescribed criteria. Manufacturers of healthcare technology are incentivised to investin cyber security for their products, consequently giving them a potential competitiveedge as customers see that certification is dependent upon a security-by-designapproach to product development. When considering how the aforementionedpotential of telemedicine and eHealth will rely heavily on the Internet of Thingsand the newest 5G data transmission standards, these new supernational legalframeworks can add a significant level of resilience; as it takes a stride in ensuringgood cyber security as the foundation for trust in digital systems that should be ableto guarantee information security.147Until legal frameworks such as the aforementioned legislation on harmonizedcertification have been implemented, security concerns remain a relevant factorinfluencing the users’ trust in the healthcare system’s ability to protect their sensitivedata. The rise and investment in telemedicine to take advantage of the internetin support of ambulatory, more self-responsible monitoring and treatment in a“hospital-at-home” is heavily reliant upon security-by-design solutions minimizingor excluding the possibility of data breaches caused by unaware end-users. Suchuser-driven, self-monitoring of health care is ideal from a cost saving efficiencyperspective as it is designed for people in certain risk-groups, people that mightotherwise be re-hospitalized, and to assist people who are more likely to recoverfaster in their own home, whilst providing autonomy and enhanced quality of life.However, patients are required to place complete trust into their own network andthe integrity of the data presented to them, or that they are required to share; aswell as ensuring that the precise data that they need are available to them, theirdevices as well as to their healthcare professional, whenever it is needed and inreal time. Lastly, the patient data must remain confidential in accordance withlegal requirements. These demands are dependent upon a stable information andcommunication technology platform. Currently, many experts regard the Internet assimply not yet good enough for eHealth due to persisting reliability, availability andsecurity issues. Each of which can undermine a patients’ wellness due to the explicitrisk related to telemedicine application and its dependency upon data managementand data security.Where even unintended individual human errors (slips) can cause massivedata breaches, sensitive data of high value administered by poorly prepared andinsufficiently aware healthcare professionals pose a huge incentive for maliciouscyber attacks. The resulting limited trust in the system’s integrity directly impairsthe political incentives to facilitate digitalization further and increases the economicand organizational costs of further establishing robust cyber resilience. Precautionsto ensure cyber resilience slow down or functionally impair the overall serviceperformance by patients, due to delays, less user-friendly interfaces and identificationrequirements. As a result of diminished trust into both privacy and security, usersmay only reluctantly share highly personal data such as stigmatizing mental andsexual health conditions with a depersonalized and intransparent environment(Shenoy and Appel 2017). There is, to the best of our knowledge, currently noevidence-based knowledge on how far cyber security impairs the trust intothe healthcare system and how reduced trust into cyber resilience impairs itsperformance or cost-effectiveness. Considering these likely side effects of hastily148implemented digitalization without parallel implementation of a robust, transparentand technologically advanced cyber security strategy, we find the transparent,user-friendly and so far outstandingly successful cyber resiliency strategy providedby the Estonian example as a promising blueprint for future developments inother countries.6. ConclusionsThe digitalization of healthcare environments is changing the way healthcaresystems operate and how they are organized, with significant changes for thepatient’s roles, responsibilities and opportunities. The benefits are manifoldand relate to improved decision-making processes, availability of services,cost-effectiveness, and patient autonomy. The foundation of these changes isthe constant and instant availability and exchange of patient- and service-relateddata that coordinate actors, communicate health-related patient data, provide thefoundations for decision-making and facilitate the administrative processes at large.The comprehensive datasets occurring in this process provide the basis of the benefitsof digitized healthcare, as well as the major challenge and vulnerability. A series ofmassive data breaches and enormous growth rates of cybercrime targeting valuabledata processed in the healthcare systems, as well as a number of unintended breachesresulting from human failures, demonstrate an overproportional vulnerability of thissocietal sector, in which cyber security awareness is considered to lag behind otherareas where security concerns appear more intuitively natural.The health sectors’ drive for digitalization to realize opportunities in, for example,eHealth and telemedicine will require far greater investment in cyber resilience ifavailability and security are to match the potential and ambitions of efficiency andeffectiveness. Any progress towards ensuring the digitalization of the health sectorneeds to be measured against the current vulnerabilities to confidentiality, integrityand availability of before, between and after treatment data. Critical applications thatare implemented to support achieving sustainable health goals may lack sufficienttrust and reliability. Contact-tracing applications as they are introduced in the laterphase of the COVID-19 pandemic have raised privacy and security concerns. Whileit is currently too early to thoroughly evaluate the outcomes of this particularlycontroversial symbol of accelerated digitalization in terms of public health benefits,the controversy around contact tracing apps provides an impressive example of thenecessity of trust and its tight relationship with healthcare outcomes.We argue that trust in healthcare systems affects its performance in a numberof ways: (a) Patients hesitate to share sensitive data on their personal conditions if149these are likely to be exchanged or administered in online databases and possibleaccessed by third parties. (b) The enormous additional investments in cyber securitymeasures such as security-by-design or the engagement of qualified cyber securityprofessionals as well as the related infrastructure increasing costs, planning andimplementation time for digital innovations and thus slows down the transformationprocess. (c) Educational efforts by users including healthcare professionals, healthcareadministrators, patients and third parties (for example, insurers) are necessary todevelop cyber hygiene and reduce the risk of human failures, adding further to thetime and financial costs of digitalized services.Cyber security is fundamentally a human factor challenge and will requiresignificant investment and research into achieving ways to develop a sharedunderstanding across legal, institutional and national boundaries. The securityaspect needs to be incorporated in the very early stages of designing and making it acentral part of all digitalization processes.While these measures to be taken may facilitate cyber resilience, increase thetrust into a digitized healthcare with increased patient autonomy counteracting thesimultaneous risk of privacy threats, parallel efforts have to be undertaken to ensurethat all societal groups benefit from a more digitized healthcare. The empowermentand patient autonomy that comes with digitalization is of particular advantage forpatients who know how to make use of their opportunities. Those with less technicalaffinity, but empowered, cannot take responsibility for their data security. Thisrequires a balance of giving users full control and oversight over the use of theirsensitive data, but without giving them the responsibility of making decisions thatcould unintentionally compromise their privacy.In sum, the digitalization of healthcare is a potential major breakthrough in thedevelopment of sustainable healthcare worldwide. Sustainable healthcare systemtransformation, however, builds on the trust of its users and all measures taken tofurther improve the systems’ effectiveness are subject to cost-benefit-analysis. Cyberresilience of healthcare systems plays an important role in building and ensuringongoing trust as a central pillar of sustainability.Author Contributions: All authors contributed substantially to all phases of the writingprocess, have approved the submitted version and agree to be personally accountable for thecontribution as regards the accuracy and integrity of any part of the work.Funding: This work was funded by the Research Council of Norway (Project nr. 302941).Conflicts of Interest: The authors declare no conflict of interest.150ReferencesAtasoy, Hilal, Brad N. Greenwood, and Jeffrey Scott McCullough. 2019. The digitization ofpatient care: A review of the effects of electronic health records on health care qualityand utilization. Annual Review of Public Health 40: 487–500. 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This article is an openaccess article distributed under the terms and conditions of the Creative CommonsAttribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).154Sustainable Work Ability during Midlifeand Old Age Functional Healthand MortalitySubas Neupane and Clas-Håkan Nygård1. IntroductionBecause of changes in demographics, the world is facing the challenge of agingsocieties, which can cause financial burden, as they generate less income for healthservices and pension systems, as well as a shortage of hands for production and takingcare of the elderly. To overcome this problem, many national policies aim to furtherextend working careers by increasing the statutory retirement age. Extended workingcareers mean longer labor market participation and longer work exposure. However,if people should be in the labor market for a longer period, they ought to be in goodphysical and mental health and have access to more flexible working arrangements,healthy workplaces, and lifelong learning and retirement schemes. The process ofliving and working conditions that enable people to continue working for a longerperiod is here called sustainability (Eurofound 2015). Good health and wellbeingthroughout life is one of the 17 sustainable goals of the United Nations (UN 2015),which ensure a healthy working life and promote the wellbeing of people at allages. This means one of the key themes addressed by this SDG target is promotinghealth and safety in the workplace to ensure a healthy working environment and,thus, healthy lives during working careers and beyond by decent work, employmentcreation, social protection, and rights at work for productive employment andsustainable economic growth. Job quality and good working conditions contributeto wellbeing and a good quality of working life (Drobnič et al. 2010). However,workplace health and working conditions in most developing countries are generallypoor in many work sectors, which means that the overall subjective wellbeing is poorin these countries (Robertson et al. 2016; Eurofound and ILO 2019).Quality of life is one of the dimensions of sustainable work and is perceived todecrease by age; however, when controlled for potential factors, the effects of age maydisappear. Sustainable work is an important topic worldwide. Several indicators, suchas sustainable employment, employability, work engagement, and organizationalcommitment have been used in the literature to describe sustainable work concepts(Ilmarinen et al. 2005; Van Dam et al. 2017). However, making sustainable work155requires a balance between the requirements of work, such as demands and control,and the needs of individuals, such as an individual’s capacity, as both change overtime. Moreover, whether a healthy and longer work-life is possible for every personremains unclear (Ilmarinen 2013). Good health among individuals is a prerequisitefor this continuation, but knowledge about the possible health consequences ofan extended working life is limited. Earlier research shows that retirement ratherthan an extended working career tends to be a relief for those who suffered fromsuboptimal self-rated health, sleep disturbances, fatigue, depression or headachediseases (Westerlund et al. 2009; Stenholm et al. 2016), or musculoskeletal pain(Neupane et al. 2018), whereas retirement seems to have an immediate positiveeffect on the risk of the incident of chronic conditions. Other studies have shownthat exposure to poor working conditions at earlier stages of the working life mayincrease the possibility of poor health and disability in later life. The number of riskfactors of physical functioning in later life start to accumulate from early to midlife,and include behavioral, environmental, lifestyle-related, and sociofactorial factors(Guralnik et al. 1993; Brown and Flood 2013). Yet, only a little is known about thelink between work-related exposures from midlife and functional health in laterlife. There exists some evidence on the negative association between occupationalphysical activities (Hinrichs et al. 2014) and work stress (Verbrugge and Jette 1994),as well as work ability (Kulmala et al. 2014) in midlife and mobility limitations inlater life. Physically demanding work with vigorous occupational physical activityin midlife increases the risk of mobility limitations in later life (Hinrichs et al. 2014),which could eventually progress to disability. Similarly, lower work-related stress(Kulmala et al. 2014) and better work ability (von Bonsdorff et al. 2016) in midlifehave been reported to be protective to mobility limitations in later life, while poorwork ability was reported to be associated with mortality (von Bonsdorff et al. 2011).The occupation in midlife also plays a vital role in the onset of later lifedisability, with unskilled blue-collar workers being the high-risk group compared towhite-collar workers (Prakash et al. 2016). Work-related high physical exposure andjob strain in midlife were strongly associated with the severity of disability in laterlife (Prakash et al. 2017).Sustainable work ability is a multifaceted concept that involves the matchingof the needs and abilities of the individual with the quality of jobs on offer.Although sustainable work ability is often mentioned in reference to an agingworkforce, it should be noted that sustainability relates to workers of all ages(Van Vuuren and Van Dam 2013). In order to stay in the workforce until retirement,it is important that employees work in a healthy workplace, whatever their age.156Work ability, defined as people’s ability to cope with their work demands, is abroad concept and an important human capital of workers throughout their workingcareer (Ilmarinen 2019). It requires continuous processes at workplaces, aiming toimprove the fitting of human resources and work environments together. Properworking conditions enable a good fit between work and the characteristics of theindividual throughout their working life. To achieve this dual goal, employers arerequired to develop new solutions for working conditions and career paths thathelp workers to maintain their work ability over an extended working life. Workability tends to decline with age (Ilmarinen Juhani and Matti 1997), although themean work ability of the working population between the ages of 20 and 65 yearsremains at a good or excellent level (Gould et al. 2008). In this chapter, work abilitymaintained at good or excellent during the work career was considered sustainablework ability. We studied the impact of sustainable work ability by examiningtrajectories over 16 years. Wellbeing was measured in terms of mobility limitationsin old age after 12 years using longitudinal data on employees in a large amountof blue- and white-collar municipal occupations. We also studied the difference insurvival and any cause of death among people in work ability trajectory groups. Ourhypothesis was that people with sustainable work ability during midlife would haveless mobility limitations and better survival than those who did not have sustainablework ability.2. Materials and MethodsThe Finnish Longitudinal study on Aging Municipal Employees (FLAME)was conducted among municipal workers from 1981 to 2009 (Ilmarinen et al. 1991;Tuomi et al. 1997; von Bonsdorff et al. 2011). At baseline, in 1981, a postalquestionnaire was sent to 7344 municipal workers all around Finland. In total,6257 (85.2%) 44–58-year-olds having worked as municipal workers for at least 5 yearsresponded. Follow-up data were collected with postal questionnaires in 1985(n = 5556), 1992 (n = 4534), 1997 (n = 3815), and 2009 (n = 3093) (von Bonsdorff et al.2011). In this study, we analyzed work ability data from 16 years of follow-up from1981 to 1997, which covers the work career of people from midlife until retirement.For inclusion in the trajectory analysis, the respondent must have replied at baseline,while in the regression analysis, we analyzed only those participants who hadinformation on the outcome variable (mobility limitations) from the last round (2009)of follow-up (n = 2918). The respondents’ exact retirement dates and mortality dates,from any cause, were obtained from the national pension registry and linked withthe survey data. Figure 1 presents the follow-up process in detail.157The Ethics Committee of the Finnish Institute of Occupational Health, Helsinki,Finland approved the study.2.1. Measurement of Variables2.1.1. Work AbilityIn this analysis, we used two types of work ability measures from the workcareer. Work ability index (WAI) was the composite measure of seven items (Table 1)based on subjective survey instruments (Ilmarinen et al. 1991). WAI indicates thewellbeing, health status, and quality of life as it measures how good a worker is atpresent and in the near future, and ability to work with respect to work demands(Ilmarinen et al. 2005). WAI was measured only at baselineTable 1. Items of work ability index.Items Range1. Current work ability compared with the lifetime best 0–102. Work ability in relation to the demands of the job 2–103. Number of current diseases diagnosed by a physician 1–74. Estimated work impairment due to diseases 1–65. Sick leave during the past year (12 months) 1–56. Own prognosis of work ability 2 years from now 1–77. Mental resources 1–4The WAI ranges from 7 to 49, and the higher the score, the better the work ability.Based on the scores, WAI has been classified into four standard categories (poor 7–27,moderate 28–36, good 37–43, and excellent 44–49) (Gould et al. 2008). In this analysis,good and excellent work ability was combined.The work ability score (WAS) was measured using a single item; the firstitem of the WAI is “current work ability compared with the lifetime best” witha score from 0 to 10, where 0 is incapable to work and 10 is the work ability atits best (von Bonsdorff et al. 2011; Ebener and Hasselhorn 2019). WAS is stronglyassociated with WAI and can be used as a simpler indicator for assessing workwellbeing (Ahlstrom et al. 2010). WAS was measured identically in all four surveys.The developmental patterns of work ability from four time points were used as themain independent variable in this analysis.1582.1.2. Mobility LimitationMobility Limitations (MLs) as an outcome of interest in this study weremeasured using self-reported questionnaires distributed among the participantsin the last round of the follow-up in 2009. The International Classification ofFunctioning, Disability, and Health (ICF) was used to define the mobility limitations(World Health Organization 2001). Nine items related to activities and the mobilityof the participants were used to create a final score. Table 2 shows the items includedin defining mobility limitations. All the items, except walking 2 km, were assessedon a four-point scale of difficulty (manage without difficulties, manage with littledifficulties, manage with lots of difficulties, and cannot manage). Walking 2 km wasassessed on five levels (no difficulty—cannot manage with the help of others as well).In this analysis, all nine items were first dichotomized (no difficulty vs. at least somedifficulty), then combined to make a summary score of 0 to 9 (score ‘0’ representedno limitations in carrying out any of the 9 tasks and those who had at least somelimitations in carrying out one or more of the 9 tasks scored ‘1–9’ depending on thenumber of tasks entailing limitations) (Prakash et al. 2019; Hinrichs et al. 2014).Table 2. International classification of functioning (ICF), disability, and healthcategories used to create mobility limitation (ML) (0–9).Mobility List of Categories Questions RangeChanging andmaintaining bodypositionChanging basicbody position1. Squatting and standing upagain? 1–42. Bending down deep? 1–4Maintaining a bodyposition3. Maintaining bodyposition/sitting still for 2 h? 1–4Carrying movingand handlingobjectsLifting and carryingobjects4. Lifting and carrying more than10 kg? 1–4Fine hand use 5. Precise movements of hands? 1–4Hand and arm use 6. Lifting hands over the head? 1–4Walking andmovingWalking 7. Walking 2 km? 1–5Moving around 8. Running 100 m? 1–49. Climbing three floors/stairs? 1–41592.1.3. MortalityThe study participants were followed for mortality between 1 January 1981 and31 July 2009. Data on date of death, from any cause, were obtained from the FinnishNational Population Register.Demographic InformationAge (44–58 at baseline) was used as a continuous and categorical (44–49 vs.50–58 years) variable in the analyses. Occupational class (white-collar, blue-collar)was created based on a detailed analysis of job profiles among 88 occupational titles,clustered into 13 job profiles and later, into two major groups (Kulmala et al. 2014;Prakash et al. 2016). Information on gender (female/male) was obtained from thequestionnaire survey.Lifestyle CharacteristicsLeisure-time physical activity (LTPA) in the past year was collected in fivecategories (1—brisk exercise at least twice a week; 2—brisk exercise at least oncea week; 3—some exercise at least once a week; 4—some exercise less than once aweek or no exercise) and classified as high (1–2) or low (3–4) (Neupane et al. 2018).BMI (kg/m2) was calculated using self-reported height and weight and dichotomizedas <25.0 (normal) or ≥25.0 (overweight/obese). Those reporting current smoking>1 cigarette per day or past smoking were classified as smokers.MorbidityInformation on morbidity was obtained by the question “Please indicate in thelist below which diseases or impairments you have at present. In addition, checkwhether a physician has diagnosed or treated this condition”. The list covered47 items. We used the following categories (yes/no) of physician-diagnosed diseases:musculoskeletal, cardiovascular, respiratory, and metabolic diseases. The informationon the number of diseases was summed up and categorized into three—0, 1, 2,or more morbidities.Physical WorkloadPhysical workload at baseline was assessed with eight questions about currentexposure to the following: vibration, repeated movements, standing still, bent ortwisted postures, other poor postures, continuous walking or movement, carryingobjects, and sudden strenuous efforts. Response options ranged from 0 (not at all)160to 4 (quite often). The composite score (Cronbach’s α = 0.82) ranging from 0 to 32was dichotomized into high and low at the median value of 12, with median valueincluded in high physical workload (Neupane et al. 2018).2.2. Statistical AnalysesWe first analyzed the mean distribution of the work ability index by age (as acontinuous variable) using the box plot method. The cut-off line was plotted toseparate out ‘good and excellent’, ‘moderate’, and ‘poor’ work ability.Growth mixture modeling (GMM) was applied to identify trajectories of thework ability score (WAS) from four time points. The basic assumption of GMMis that all individuals follow the growth pattern of a random variation. GMMalso accounts for within-class variations in the estimation of class memberships(Ram and Grimm 2009). All the study participants who responded at baseline tothe survey were included in the trajectory analysis. The number of trajectoriesand their shape were determined first. The quadratic function best represented thepatterns of change in the WAS. The final model was chosen based on a range offit criteria (see appendix), including the Akaike Information Criterion (AIC), theBayesian Information Criterion (BIC), sample size adjusted BIC, entropy, and posteriorprobabilities and meaning and their interpretability (Nylund et al. 2007). Based onthese, a three-trajectory model was selected. The trajectory groups were illustratedby plotting the means of the WAS against survey year.Baseline characteristics of the study participants were presented as frequenciesand percentages by work ability trajectory. The difference between trajectories wastested by the Chi-square test.Sixteen-year trajectories of the WAS were then used to study the associationswith mobility limitations of the people after 12 years. A generalized linear model(GLM) with a Poisson function was used to calculate the incidence rate ratios (IRR)and their 95% confidence intervals (CIs) for the associations. Three models werefitted, the first model was the bivariate association of the trajectories of the WASwith mobility limitations. Bivariate association of the sociodemographic, behavior,and work-related variables from the baseline with the mobility limitations wasalso calculated in Model I. In Model II, the association of work ability trajectorieswith mobility limitation was adjusted for sociodemographic variables (age, gender,and occupational class). Model III was further adjusted for all the sociodemographic,lifestyle-related, morbidity, and work-related variables from Model I. The estimateswith their 95% CIs are also presented for all the covariates used in the Model III.161Nelson–Aalen cumulative hazard estimates were plotted for mortality fromany cause by trajectory membership. The follow-up time started from the baseline,1 January 1981, and ended with censoring resulting from death or end of follow-upin 2009.Trajectory analysis was conducted in Mplus v7.2 and the other analyses inR-studio and Stata v15.3. ResultsFigure 1 shows the mean distribution of work ability index at baseline by age ofrespondents. It shows that, in general, the work ability decreases with increasing age.The mean work ability was maintained as either good or excellent until the age of51 years; after that, the mean level of work ability index decreased to moderate.Work Ability IndexAge (years)504030201044 58Good and excellentModeratePoor48 5046 52 5654Figure 1. Distribution of the work ability index (7–49) by age (44–58 years) amongstudy participants at baseline.Participants were followed for 16 years after the baseline survey until 1997 to seethe changes in WAS. We used trajectory analysis to see the change in work ability scoreusing self-reported WAS data from four time points. Figure 2 shows the trajectoriesof mean WAS at different follow-up times. We found three distinct trajectories.1629876543210Work Ability Score1981 1985 1992 1997Year of SurveyGood work ability (65.1%) L-shaped decreasing work ability (25.2%)U-shaped decreasing work ability (9.7%)Figure 2. Trajectories of the mean of the work ability score from 1981 to 1997 amongstudy participants.Of the total subjects studied, the majority (65%) had good work ability duringthe 16 years of follow-up. The mean work ability score was about 8 at the baseline,which slightly decreased to, on average, 6 during the follow-up. This group of peoplewho maintained good work ability during their work career was considered here asthe sustainable work ability group. About 25% of the study participants had L-shapeddecreasing work ability. They started with a mean WAS of 6 at baseline, which thenlater decreased in L shape during the follow-up. The third group consisted of about10% of the participants, who had a U-shaped decreasing work ability. They startedwith a mean WAS of 5 at baseline, which decreased as U-shaped during the follow-up.In the good and L-shaped decreasing trajectories group, the decrease in the workability score was steep until 1992; after that, the work ability mostly remained constantor improved. Meanwhile, among those in the U-shaped trajectory group, a slightimprovement in work ability was observed already from 1992.Table 3 shows the baseline characteristics of the study population by work abilitytrajectories. There were significantly more younger workers who had a good workability trajectory compared to their older counterparts, while more older workershad L- or U-shaped decreasing work ability. Significantly more women, white-collarworkers, high LTPA, low (<25) BMI, no or one comorbidity, and workers with lowphysical workload had good work ability. More men and more blue-collar workershad L- and U-shaped decreasing work ability. Meanwhile, ther was no significantdifference in the distribution of work ability trajectories by smoking status.163Table 3. Baseline characteristics of the study sample by work ability trajectory groups.Characteristics TotalN = 2918Trajectory MembershipGood(n = 2083)L-ShapedDecreasing(n = 661)U-ShapedDecreasing(n = 174)p-ValueAge (Years) <0.00144–49 1529 1149 (75.1) 319 (20.9) 61 (4.0)50–58 1389 934 (67.2) 342 (24.6) 113 (8.1)Gender <0.001Women 1858 1348 (72.5) 410 (22.1) 100 (5.4)Men 1060 735 (69.3) 251 (23.7) 74 (7.0)Occupational class <0.001White-collar 1688 1318 (78.1) 307 (18.2) 63 (3.7)Blue-collar 1230 765 (62.2) 354 (28.8) 111 (9.0)Smoking 0.447No 1873 1345 (71.8) 424 (22.6) 104 (5.6)Yes 1045 738 (70.6) 237 (22.7) 70 (6.7)LTPA † <0.001High 1505 1130 (75.1) 294 (19.5) 81 (5.4)Low 1354 915 (67.6) 350 (25.9) 89 (6.5)BMI ‡ <0.001<25.0 1442 1091 (75.7) 283 (19.6) 68 (4.7)≥25.0 1449 976 (67.4) 368 (25.4) 105 (7.2)Comorbidity <0.0010 1337 1145 (85.6) 168 (12.6) 24 (1.8)1 810 557 (68.8) 202 (24.9) 51 (6.3)2 or more 771 381 (49.4) 291 (37.7) 99 (12.8)Physical workload <0.001Low 1464 1195 (81.6) 229 (15.6) 40 (2.7)High 1454 888 (61.1) 432 (29.7) 134 (9.2)† Leisure-time physical activity; ‡ Body mass index.164The distribution of mean value of mobility limitations with their 95% CIs bywork ability trajectories is presented in Table 4. It shows that the mean number ofmobility limitations was lowest (mean 3.38, 95% CI 3.27–3.49) among those in thegood work ability trajectory group, while it was highest (5.51, 95% CI 5.13–5.90)among those in the U-shaped decreasing trajectory group. Similarly, in the sametable (Table 4), the mean work ability score is presented by survey year. This showsthat the mean score decreased by survey year because of the increase in age of theworkers in each survey round.Table 4. Distribution of the mean mobility limitations (0–9) according to workability trajectory group and mean work ability score (0–10) by year of survey.Work Ability Mobility Limitation Mean, 95% CIGood 3.38 (3.27–3.49)L-shaped decreasing 4.71 (4.51–4.92)U-shaped decreasing 5.51 (5.13–5.90)Year of Survey Work Ability, Mean ± SD1981 7.65 ± 1.701985 6.93 ± 2.141992 5.62 ± 2.791997 5.65 ± 2.42The associations of work ability trajectories with the mobility limitation arepresented in Table 5. It shows strong and statistically significant associations ofL-shaped and U-shaped decreasing work ability trajectories with increased mobilitylimitations compared to those belonging to the good work ability trajectory group,so-called people with sustainable work ability. The crude model (Model I) shows thatbelonging to the L-shaped and U-shaped decreasing work ability trajectory groupswas associated with increased risk of mobility limitations in the 12 years follow-upcompared to those in the good work ability trajectories group. The associationsremained statistically significant even after adjusting for age, gender, and occupationalclass in Model II. After further adjustment with smoking status, LTPA, BMI, morbidity,and physical workload in Model III, the association remained strong and statisticallysignificant (IRR for L-shaped decreasing work ability 1.24, 95% CI 1.18–1.30 andU-shaped decreasing work ability 1.37, 95% CI 1.28–1.47). The magnitude of theassociation was higher for those in the U-shaped decreasing trajectory group ineach model.165Table 5. Associations of 16-year work ability trajectories with mobility limitationsin 28 years follow-up. Incidence rate ratios (IRR) and their 95% confidence intervals(CIs) from a Poisson regression model.Characteristics N † = 2533IRR, 95% CI for Mobility LimitationModel I Model II Model IIIWork abilityGood 1751 1 1 1L-shaped decreasing 615 1.40 (1.34–1.46) 1.37 (1.31–1.42) 1.24 (1.18–1.30)U-shaped decreasing 167 1.65 (1.54–1.76) 1.57 (1.46–1.68) 1.37 (1.28–1.47)Age (Years)44–49 1278 1 1 150–58 1260 1.28 (1.23–1.32) 1.23 (1.18–1.27) 1.19 (1.14–1.23)GenderWomen 1707 1 1 1Men 826 0.80 (0.76–0.83) 0.76 (0.73–0.79) 0.73 (0.69–0.76)Occupational classWhite-collar 1460 1 1 1Blue-collar 1078 1.13 (1.09–1.18) 1.13 (1.09–1.17) 1.03 (0.99–1.08)SmokingNo 1639 1 1Yes 899 1.00 (0.97–1.04) 1.11 (1.06–1.16)LTPA †High 1252 1 1Low 1233 1.25 (1.20–1.29) 1.16 (1.11–1.20)BMI<25.0 1202 1 1≥25.0 1313 1.32 (1.27–1.37) 1.25 (1.20–1.30)Comorbidity0 1092 1 11 731 1.27 (1.21–1.33) 1.16 (1.11–1.22)2 or more 715 1.53 (1.46–1.60) 1.28 (1.22–1.34)Physical workloadLow 1230 1 1High 1308 1.27 (1.22–1.32) 1.08 (1.04–1.13)† Participants with at least some mobility limitations. Model I: Bivariate model; Model II:Adjusted for age, gender, and occupational class; Model III: Adjusted for all variables fromModel II + smoking, LTPA, BMI, comorbidity, and physical workload.166The increasing rate of mobility limitations was found to be associated witholder age, those who never smoked, low LTPA, higher BMI, those with one or morecomorbidities, and those who reported high physical workload. These associationsremained statistically significant in the final model (Model III). Meanwhile, comparedto women, men were associated with lower incidence rates of mobility limitationsand the association of blue-collar workers with mobility limitations was not clear inthe final model.Figure 3 presents the Nelson–Aalen cumulative hazard estimates by work abilitytrajectories group for all-cause mortality. The estimates in the different trajectorygroup already started to diverge after 5 years from the baseline survey. The hazardwas highest among those in the U-shaped decreasing work ability trajectory groupand lowest among those in the good work ability trajectory group. The estimates inthe good and L-shaped decreasing work ability trajectory group started to divergeafter 10 years of follow-up.Cumulative hazard0 3010 155 20 250.80.60.40.20Time since baseline (years)U-shaped decreasing L-shaped decreasing Good work abilityFigure 3. Nelson–Aalen cumulative hazard estimates of all-cause mortality by workability trajectory group between 1981 and 2009.4. DiscussionWe used good work ability as an indicator of sustainable work ability in along-term prospective follow-up study of municipal employees to study the health167impact in later life. We found that about two-thirds of our study population had goodor sustainable work ability during their late work career. Sustainable work abilitywas a very strong predictor of good health outcome in terms of mobility limitations inold age. People belonging to the trajectories of decreasing work ability had increasedrisk of mobility limitations in old age. They also had a high cumulative hazard ofdeath from any cause (i.e., worst survival) compared to those with a good workability trajectory. Overall, our findings supported the importance of a sustainablework ability during the latter part of the work career.Work ability has been used as a continuity construct since its establishment inthe Finnish Institute of Occupational Health (Tuomi et al. 1998; Ilmarinen 2009, 2019).It considers the surrounding organizational and societal context, providing a wideperspective on the relationship between the individual and the work and socialenvironment (Ilmarinen 2009). Work ability has been supported by the goal to prolongwork careers and to prevent work disability (Gould et al. 2008). Work ability is alsoassociated with health-related quality of life (Sörensen et al. 2008), which indicateswellbeing at present and its sustainability. It is, therefore, important to maintainwork ability during the work career for better quality of life at midlife and beyond.In our study, work ability was fairly stable for about two-thirds of the peopleduring 16 years of follow-up in their midlife and the rest had decreasing workability until the first 11 years of follow-up andm, then, slowly improved after that.This indicates that the majority of the employees had sustainable work ability andwellbeing at midlife. The work ability index at baseline also shows that the meanwork ability was maintained either at good or excellent until the age of 51 years;after that, the mean level of work ability index decreased to moderate. There were20–25% of 44–49 years old who had moderate or poor work ability. They risk losingtheir work ability if no preventive actions are taken. The stability of work abilityindicates that the employees have enough resources to cope with their job demands,although there is a wide variation between white- and blue-collar occupations butless variation by gender. The majority of our study participants (75%) retired duringthe second round of the follow-up in 1992, and by the end of 1997, almost all (99%)were retired. The decreasing work ability trajectory group improved their meanwork ability score after 1992, which means that retirement improved their perceivedwork ability. This means the quality of life and wellbeing of people improves whenthere is no pressure of work demands.These results of our study are consistent with the French GAZEL study, showingthat perceived health in older workers, exposed to poor working conditions,is relaxed after retirement (Westerlund et al. 2009). Another study also showed168the health benefits of retirement but only for upper occupational class employees(Mein et al. 2003). Employees will be relieved from their physical and mentaldemands of the work, which is beneficial to health and quality of life.Consistent with our results, similar findings have been reported in earlierstudies. A study from the USA reported three trajectories of work ability with 74%having good work ability, 17% declining, and only few, 9%, having poor work ability(Boissonneault and de Beer 2018). An earlier study, from our FLAME study but witha longer follow-up, until old age, reported five trajectories of work ability, with asubstantial proportion of individuals maintaining their work ability at a moderatelevel (von Bonsdorff et al. 2011). Our earlier study among younger working aged(mean age 42 years) people in the manufacturing industry showed that 90% had agood work ability trajectory during six years of follow-up (Oakman et al. 2019).Trajectories of decreased work ability in either an L- or U-shape were associatedwith increased risk of mobility limitations in old age, even after controlling for theeffect of demographic, lifestyle factors, morbidity and physical workload in thebaseline. Mobility limitations in this study were used as an indicator of functionalhealth in old age. Mobility limitations are associated with poor quality of life amongolder adults and predict all-cause mortality (Bergland et al. 2017). Consistent withour findings, an earlier study reported that better work ability protects from oldage mobility limitations among those who retire due to non-disability and disability(von Bonsdorff et al. 2016). Other studies found that vigorous occupational physicalactivity (Hinrichs et al. 2014), higher work stress (Kulmala et al. 2014), and shiftwork (Prakash et al. 2019) were associated with mobility limitations in old age.We also found that among studied covariates, older age, being a woman, smoker,low leisure-time physical activity, high BMI, having multiple morbidities as well ashaving high physical workload at baseline were statistically significantly associatedwith an increased risk of mobility limitations in old age. Moreover, higher cumulativerisk of mortality from any cause was found among those in the decreasing trajectoriesgroup compared to those in the sustainable work ability group.Sustainable work ability is beneficial to everyone, industries and societyas a whole. Individuals can benefit from better work outcomes, smoothertransitions between life stages, and longer working lives from the sustainablework ability, whereas, for industries, sustainable work ability may lead to animproved efficiency or productivity. This implies that society will benefit fromhealthier populations, higher employment rates, more inclusive labor markets,and lower pressure on public budgets. Due to the ageing of the populationand the shrinking workforce, new sources of growth and economic progress are169needed where the sustainable work ability concept would be relevant. Sustainablework ability promotes a holistic approach that considers workers’ health, personalcharacteristics, family, and social responsibilities. Those with a diminishing workability can be promoted for example, decreasing physical workload, adjustingwork–rest schedules, and introducing age-management practices, flexible workingtime schedules, and teamwork (Ilmarinen and Rantanen 1999).Sustainable work ability requires sustainable employment and wellbeing at work,which then enhances the quality of work life and satisfaction. The aging workforce alsoemphasizes the importance of sustainable employment; therefore, workers are willingto work after their normal retirement age (Armstrong-Stassen and Schlosser 2008;Gobeski and Beehr 2009), which can have the potential to achieve sustainableeconomic growth. “Promote sustained, inclusive and sustainable economicgrowth, full and productive employment and decent work for all” is one partof the agenda of the SDGs. Work organizations may have an important role,which can draw attention to an age-supportive atmosphere for workers of all ages(Oakman et al. 2016), although age-related changes are largely specific to individuals,with wide interpersonal variability (Sluiter 2006). A major strength of our studywas the use of long prospective follow-up data from a representative population ofFinnish municipal occupations. Among other strengths, there was a high responserate at baseline and follow-ups, use of official registers data on retirement andmortality, and elimination of recall bias. About 50% of the baseline respondents alsoparticipated in the last survey wave in 2009 after almost three decades. One canconsider some of the limitations of this study while inferring the findings. The workability scores as well as mobility limitations were both self-reported, which is possiblysubject to information and recall bias and could lead to over-reporting. Nevertheless,these measures are validated tools and have been used extensively in earlier research(von Bonsdorff et al. 2011; Prakash et al. 2019; Hinrichs et al. 2014; Ilmarinen 2019).Another strength was that we used ICF classification of physical functioning that hasbeen validated and frequently used in earlier studies (Hinrichs et al. 2014).5. ConclusionsIn all, we found that the majority of people maintain fairly good work abilityduring their work career in midlife, while a few have declining work ability.Sustainable work ability protects from mobility limitations in old age, while decreasingtrajectories of work ability are associated with increased risk of mobility limitationsas well as premature mortality. It is, therefore, important to detect workers with170diminishing work ability in order to promote their work ability and prevent fromfuture disability.Author Contributions: C.-H.N. was involved in data collection of initial surveys. S.N.analyzed the data, interpreted results, and drafted the manuscript. S.N. and C.-H.N. criticallyread and revised the manuscript and accept the final version as submitted.Funding: S.N. was partly supported by the Competitive State Research Financing of the ExpertResponsibility area of Tampere University Hospital.Acknowledgments: We would like to thank the Finnish Institute of Occupational Health forthe opportunity to use their data, and especially Jorma Seitsamo for providing the data for thecurrent study. We would also like to thank Juhani Ilmarinen for his support in planning ofthe manuscript.Conflicts of Interest: The authors declare no conflict of interest.ReferencesAhlstrom, Linda, Anna Grimby-Ekman, Mats Hagberg, and Lotta Dellve. 2010. The work abilityindex and single-item question: Associations with sick leave, symptoms, and health—Aprospective study of women on long-term sick leave. 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