PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025

32 Acting early on NCDs The Partnership for Health System Sustainability and ResilienceThe persistence of largely preventable respiratory burden suggests systematic suboptimal management of respiratory diseases such as COPD and asthma, environmental factors driving respiratory disease emergence and exacerbation, and limited access to pulmonary rehabilitation. Gender differences in respiratory disease trends mirror those seen in lung cancer, reflecting historical smoking patterns. Germany reports increased deaths from respiratory diseases including COPD particularly among women, contributing to the country’s overall deceleration in life expectancy gains (IHME, 2023). Hospital admissions for COPD and asthma ranged from 23 per 100,000 population in Italy to 193 in Germany in 2021 (OECD, 2023b). Between 2011–2021, Italy achieved a remarkable 79% reduction (from 109 to 23 per 100,000), while Poland decreased from 281 to 83 per 100,000 (OECD, 2023b). These admission rates are considered indicators of primary care effectiveness, as many respiratory exacerbations are potentially preventable through ambulatory management. As with CKD, chronic respiratory diseases are heavily underdiagnosed: studies estimate two-thirds of people with airflow obstruction have no prior diagnosis (Delmas et al., 2021). Greece, despite having among Europe’s highest smoking rates at 32.8% in 2022 (WHO, 2025g), lacks systematic tracking of asthma and COPD hospital admissions entirely. Japan reports COPD awareness at only 27.8% as of 2019, despite setting an 80% target, highlighting the global challenge of respiratory disease visibility (MHLW, 2022a). Without comprehensive smoking cessation programmes and improved air quality monitoring integrated with early detection strategies, the respiratory disease burden will continue growing as populations age and environmental exposures persist. Risk factors and inequalities The persistence of modifiable risk factors across diverse cultural contexts and policy environments reveals both the complexity of behaviour change and the powerful influence of environmental and commercial determinants on population health. These risk factors do not distribute randomly but cluster systematically along socioeconomic, educational, and geographic lines, creating and perpetuating health inequalities that universal healthcare coverage alone cannot overcome. Behavioural risk factors Physical inactivity and obesity demonstrate how behavioural risk factors intertwine with social disadvantage. Critically low activity levels persist across all studied countries despite vastly different urban designs and cultural contexts. Japan reports that only 36.2% of men and 28.6% of women over 20 engage in physical activity at least twice weekly, with daily step counts declining to just 6,628 for men and 5,659 for women (MHLW, 2024b). These activity patterns map clearly onto socioeconomic position. In Germany, obesity affects 26.8% of individuals in the low educational group compared with 10.8% in the high educational group (Robert Koch-Institut, 2024a). France reveals similar disparities: 52% of factory workers were overweight or obese in 2020 compared to 35% of managers, while regional variations show obesity affecting 20% in northern regions versus 14% in the Paris region (Fontbonne et al., 2023). Italy’s regional patterns further illuminate these dynamics: the prevalence of obesity is highest in Southern Italy, a disparity linked to declining Mediterranean diet adherence, increased processed food consumption, and more limited recreational infrastructure in economically disadvantaged areas (Epicentro, 2023). Canada demonstrates a different but equally concerning pattern, with obesity prevalence increasing uniformly across all income quintiles from 23–24% in 2009/10 to 27–28% in 2019/20 (Canadian Community Health Survey, 2015). This unusual pattern of equal increase across socioeconomic groups suggests population-wide environmental changes that affect all segments of society, though the health consequences remain more severe for those with fewer resources to manage chronic conditions.