Enablers of early action3 Health system transformation demands more than clinical excellence: it requires aligned governance, sustainable financing, capable workforces, accessible technologies and climate-resilient infrastructure working together. Governance structures vary widely among the PHSSR countries. Japan’s structured approach, with dedicated ministerial divisions for each major NCD category supported by expert committees systematically integrating perspectives from key stakeholders, provides clear accountability lines and ensures that technical expertise, patient experience and implementation capacity all inform policy development. In Canada, patient-oriented research networks, particularly the Strategy for Patient- Oriented Research (SPOR) networks, successfully embed lived experience into research and policy design, with advocacy organizations such as Diabetes Canada and the HeartLife Foundation directly shaping federal frameworks. The governance challenge extends beyond structures to accountability and enforcement. Monitoring systems document problems without triggering corrective action. Strategic planning reflects political priorities and institutional capabilities more than epidemiological burden. Cross-sectoral coordination bodies exist but typically lack budgetary authority, operating through voluntary cooperation that struggles to overcome sector-specific incentives prioritizing narrow mandates over population health. However, fragmentation remains pervasive, undermining coherent NCD responses. Federal and regional systems create inconsistent coverage and duplicated efforts. Canada’s 13 jurisdictions develop separate approaches to screening, treatment and coverage with limited coordination beyond annual ministerial meetings. National oversight often lacks enforcement powers: Spain’s regional autonomy enables innovation but creates postcode lotteries in prevention. Cross-sectoral coordination remains limited despite rhetoric: Poland’s 2015 Public Health Act mandates multisectoral involvement, yet implementation stays within health sector boundaries. Meaningful stakeholder engagement in policy development is often lacking. Japan’s policy councils have limited patient and citizen representation, with technical language creating participation barriers. The 2025 review of the High- Cost Medical Expense Benefit System – affecting millions of patients – proceeded with only four committee discussions, illustrating insufficient consultation processes.54 Most critically, monitoring exists but rarely triggers corrective action. This reveals governance structures that document problems without mechanisms to compel solutions. Italy’s systematic documentation of significant regional disparities is a vital step towards addressing them but has yet to trigger effective remediation. Gaps in strategic planning reflect both political priorities and institutional capabilities. France lacks coordinated multi-annual targets for all major NCDs despite having a national health strategy, while Poland has no operational strategy for stroke. Canada demonstrates comprehensive cancer control strategies but more limited frameworks for cardiovascular, renal and respiratory diseases, with civil society organizations attempting to address gaps. Priority-setting is never a purely technical matter and reflects advocacy strength and political salience as well as disease burden.3.1 Health system governance Current landscape Acting Early on Non-Communicable Diseases: A Framework for Health System Transformation 15

Acting Early on Non-Communicable Diseases 2026