PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025

58 Acting early on NCDs The Partnership for Health System Sustainability and Resiliencecardiovascular disease (Gitt et al., 2016; Kostev et al., 2017; Mehring et al., 2017; Ose et al., 2011; Stark et al., 2011). At the same time, GPs and critics highlight challenges including administrative burden, limited flexibility for individualised treatment, and variable regional uptake (Wangler & Jansky, 2021). Overall, DMPs demonstrate both the potential and the trade-offs of scaling structured disease management through contractual and financial mechanisms. Greece has implemented innovative home-based programmes that demonstrate alternative models for chronic disease management. The “OIKOTHEN” programme brings chemotherapy and nursing care directly to patients’ homes, whilst the “FRONTIZO” programme provides integrated care for elderly patients with chronic diseases. These initiatives not only improve access but also enhance quality of life and reduce hospital burden. By bringing care to patients rather than requiring travel to facilities, these programmes address both coordination and access challenges simultaneously. Japan’s Community-Based Integrated Care System represents a comprehensive approach to chronic disease management, particularly for elderly populations. The system integrates medical care, long-term care, prevention, housing, and livelihood support within communities, recognising that effective chronic disease management extends beyond clinical services (MHLW, 2024c). However, implementation varies significantly between municipalities, with urban areas generally achieving better integration than rural regions. Regional variations in approaches to care coordination demonstrate both opportunities and challenges for local adaptation. Spain’s autonomous communities have developed diverse approaches: the Basque Country’s Integrated Chronic Care Strategy promotes coordination among healthcare levels for cardiovascular diseases, diabetes, and chronic respiratory conditions (Gobierno Vasco, 2010), whilst Madrid’s Programme for Complex Chronic Patients focuses on care continuity and telemedicine technologies (Consejería de Sanidad, 2013). However, implementation challenges reveal the complexity of translating structured care concepts into clinical practice. Italy’s regional disparities in chronic disease management are particularly striking. The implementation of care pathways for chronic diseases varies widely, with Northern regions consistently outperforming their Southern counterparts. The DM77 reform attempts to address these disparities by establishing uniform standards for community health centres, but implementation depends on regional capacity and political will. Medication management and adherence Once patients are receiving treatment, managing the complexity of multiple medications, monitoring requirements, and lifestyle modifications becomes a central challenge, particularly for those with multimorbidity. The complexity of medication regimens for NCD patients creates substantial challenges for adherence and safety. Complex regimens increase the risk of errors, drug interactions, and non- adherence, yet most health systems lack systematic approaches to medication reconciliation and review. Spain faces particular challenges with medication adherence in chronic disease management. The report notes that excessive workload means healthcare professionals have less time per patient, affecting proper medication counselling and follow-up. This time pressure prevents adequate patient education about medication purposes, side effects, and the importance of adherence, contributing to poorer disease control and increased complications (Bernal-Delgado et al., 2024). Germany’s experience with medication management in DMPs provides insights into structured approaches. Regular medication reviews are mandated within disease management programmes, with pharmacists increasingly involved in identifying potential interactions and optimisation opportunities. However, these reviews typically focus on single conditions, missing opportunities for comprehensive medication optimisation across all conditions.