PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025

61 Acting early on NCDs The Partnership for Health System Sustainability and ResiliencePOLICY LEVERS: TREATMENT AND DISEASE MANAGEMENT The evidence exposes a mismatch between single-disease guidelines and the reality of living with MTLCs: despite its prevalence, no country in our sample has developed a comprehensive MTLCs management framework. Disease management programmes demonstrate potential, but face criticism for inflexibility and administrative burden. The pandemic revealed extreme vulnerability, with major reductions in screening and substantial increases in preventable mortality, yet few countries have developed crisis-resilient NCD care plans. The gap between guideline availability and clinical implementation, combined with fragmented care coordination, means that even patients who access treatment struggle to achieve optimal outcomes. Based on the evidence examined, countries should consider the following approaches to strengthen ongoing management: ■ Develop guidelines for patients with MTLCs with practical decision-support tools Current guidelines that treat each condition in isolation become dangerous when applied to patients with multiple conditions, potentially creating unsustainable treatment burdens and harmful drug interactions. New guidelines must address common disease combinations explicitly, providing frameworks for prioritising interventions when recommendations conflict and protocols for deprescribing when risks exceed benefits. Clinical decision support tools should help reconcile competing guidelines whilst maintaining focus on what matters most to individual patients. ■ Scale disease management programmes with systematic enrolment and quality standards Structured disease management programmes have proven effective but typically reach only motivated volunteers rather than those most in need. Shifting to opt-out enrolment ensures programmes reach their target populations whilst maintaining patient autonomy. Although, this must be combined with projections of demand for disease management programmes and corresponding investment to expand capacity. These programmes must demonstrate genuine impact through improved clinical outcomes and reduced emergency care, with funding contingent on achieving both high coverage and quality benchmarks that matter to patients. ■ Strengthen medication management systems The complexity of medication regimens for multimorbid patients requires systematic approaches to reconciliation, review, and optimisation. This includes regular comprehensive medication reviews that consider all conditions together, involvement of pharmacists embedded within primary care multidisciplinary teams, and decision support tools that identify potentially harmful interactions or optimisation opportunities. ■ Invest in patient self-management support Effective chronic disease management increasingly depends on patient capabilities that current systems do little to develop. Countries need structured education programmes that go beyond information provision to build practical skills in expert patients, ongoing support systems that help patients navigate daily management challenges, and recognition that self-management support is an essential clinical service rather than an optional extra. ■ Build crisis-resilient chronic disease care Emergency preparedness must explicitly address NCD service continuity, with clear protocols for maintaining essential services, protecting vulnerable populations, and ensuring equitable access to alternative care modalities during disruptions. This requires identifying minimum service packages, developing remote management capabilities, and ensuring supply chain resilience for essential medications.