57 Acting early on NCDs The Partnership for Health System Sustainability and ResilienceFigure 15: Hospital admissions for congestive heart failure, diabetes and COPD (adults per 100,000 population), 2011 and 2021 Notes: * = 2019 data, ** = 2020 data. Source: OECD, 2023a. Disease management programmes at scale Disease management programmes (DMPs) represent one of the most significant innovations in structured chronic care delivery, attempting to bridge the gaps created by system fragmentation and address the disconnect between healthcare resource availability and health outcomes. These programmes are systematic, population-based approaches to identifying and proactively managing high-risk patients with specific chronic conditions through coordinated care interventions that span the primary-secondary care interface. They typically include standardised clinical protocols, regular monitoring schedules, patient education components, and care coordination mechanisms designed to improve outcomes whilst reducing costs through prevention of complications and avoidable hospitalisations. Germany provides perhaps the most prominent large-scale example of structured chronic disease management through its Disease Management Programmes (DMPs). Introduced in 2002 and now covering millions of patients, DMPs offer standardised care pathways for major NCDs (e.g. diabetes, cardiovascular disease, COPD, asthma) (Bundesamt für Soziale Sicherung, 2024; G-BA, 2025a; Bundesministerium für Gesundheit, 2025b). Key features include systematic enrolment, regular follow-up, patient education, and coordination across sectors. Providers receive extrabudgetary reimbursement linked to adherence with guideline-based care, and contracts are negotiated between sickness funds and physician associations (Bundesministerium für Gesundheit, 2025b). Evaluations suggest that DMPs have improved process quality and intermediate outcomes, for example better control of HbA1c among diabetes patients and reduced hospitalisations for 206167459160363287*161 262204575292391276188Congestive heart failure OECDSpainPolandJapanItalyGermanyFranceCanada 2011 2021 (or latest available)1025712111**31172156*94 153602481754244203102Diabetes 23 12913283193159*132 245260281109257133270COPD

PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025