PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025

55 Acting early on NCDs The Partnership for Health System Sustainability and Resilience 5 Tertiary prevention: Treatment and disease management Once diagnosed, NCD patients require sustained, coordinated management over years or decades, fundamentally different from acute care’s episodic interventions. Effective chronic disease management demands regular monitoring, medication optimisation, lifestyle support, and coordination across multiple providers – all whilst adapting to disease progression, emerging comorbidities, and changing life circumstances. For the growing population with multiple chronic conditions, this complexity multiplies as treatments interact and care plans conflict. This chapter examines how health systems organise ongoing NCD management, from implementing clinical guidelines to coordinating multidisciplinary care, from supporting patient self- management to maintaining service continuity during crises. It analyses disease management programmes, medication adherence strategies, the challenge of multimorbidity, and the critical role of primary care in orchestrating long-term management. The evidence includes both routine care delivery and system resilience during disruptions, as revealed by the COVID-19 pandemic’s impact on chronic disease services. Evidence-based care All studied countries have invested substantially in developing comprehensive, evidence-based clinical guidelines for major NCDs, yet the gap between guideline development and clinical implementation remains a persistent challenge across all health systems. Guideline availability and quality Spain’s HealthGuide (GuíaSalud) programme exemplifies systematic guideline development, maintaining standardised guidelines for all major NCDs and risk factors with mandated revision cycles of at least every three years to ensure currency with evolving evidence. Germany’s Association of Scientific Medical Societies (AWMF) publishes extensive condition-specific clinical guidelines; within oncology alone, the programme includes 30 guidelines covering the most common cancer types, demonstrating the depth of guideline development in specialised areas. Japan offers approximately 450 clinical guidelines through its Medical Information Distribution Service, representing one of the world’s most comprehensive collections of clinical guidance (JCQHC, 2024). A disconnect between guideline development and clinical application is a key weakness identified in several reports. Germany, despite extensive guideline infrastructure, lacks systematic mechanisms to monitor whether clinicians actually follow recommended practices. In France, low adherence to guidelines may be attributable to ineffective dissemination and suspicion amongst clinicians that guidelines undermine their autonomy. Japan lacks standardised cross-institutional monitoring systems to evaluate guidline-adherence , resulting in variations in care based on institutional experience and practitioner expertise (Japanese Medical Specialty Board, 2020). The challenge of multiple long-term conditions (MLTCs) A key limitation of current guidelines is their predominant focus on single diseases, which poorly serves the growing population with ML TCs and exacerbates the coordination challenges identified in disease management programmes. Patients with multiple conditions often receive conflicting recommendations, face unsustainable pill burdens, and encounter guidelines that fail to account for drug interactions or competing priorities.