PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025

65 Acting early on NCDs The Partnership for Health System Sustainability and ResilienceGermany’s governance structure reflects its federal system with strong Länder autonomy. Responsibility for strategic planning and implementation is decentralised and distributed across multiple levels of the health system. This arrangement engages a wide range of stakeholders but also leads to fragmentation and challenges in achieving national coherence. The Joint Federal Committee (Gemeinsamer Bundesausschuss) serves as a key decision-making body, bringing together representatives from physicians, hospitals, insurance funds, and patients, but its decisions often require lengthy consensus-building processes that delay policy implementation. Cross-sectoral coordination While some countries have experimented with coordination mechanisms and formal coordination bodies, true joint budgets between sectors remain elusive. Funding typically operates through parallel streams rather than genuinely integrated budgets across health, education, and other sectors, with these mechanisms operating within existing structures that reinforce sectoral divisions. In addition to the challenges of coordination in Federal systems, Canada also faces challenges with cross-sectoral coordination. Despite pioneering health promotion concepts internationally (Raphael et al., 2020) and with provinces like Québec and Newfoundland and Labrador legislating Health Impact Assessment for decades (Bernier, 2023), no federal Health in All Policies framework currently exists to coordinate NCD prevention across government sectors (Public Health Agency of Canada, 2021). While federal instruments such as Gender-Based Analysis Plus (GBA+), the Quality of Life Framework (Government of Canada, 2025a; Statistics Canada, 2025b), and recent networking initiatives incorporate elements of cross-sectoral thinking, these are fragmented (INSPQ, n.d.), suggesting that Canada’s reputation as a conceptual leader in health promotion has not translated into coherent operational coordination, and that this is difficult to do. Indeed, Health in All Policies (HiAP) represents an aspirational goal more than operational reality across the studied countries. In Poland, the 2015 Public Health Act creates legally binding National Health Programmes with explicit requirements for multi-sectoral involvement, yet implementation remains primarily within health sector boundaries. The fundamental challenge extends beyond coordination mechanisms to how health is valued within government decision-making hierarchies. France has developed some cross-sectoral initiatives, particularly around nutrition and physical activity, but these remain limited in scope and impact. Greece’s reactive healthcare system focuses on treating disease rather than investing in the broader determinants of health, despite evidence that upstream interventions offer greater population health impact. Spain’s regional autonomy complicates cross-sectoral coordination, as different ministries at regional level may have conflicting priorities and limited mechanisms for alignment. Strategy, planning and implementation Systematic gaps in disease coverage reveal limitations in strategic planning for NCDs across the studied countries. These gaps often reflect political priorities and institutional capabilities rather than epidemiological burden. In Spain, the national framework omits targeted approaches for several major disease categories despite their significant population impact: chronic kidney disease affects 15% of adults yet has no dedicated strategy; neurological diseases lack systematic policy attention; and rare diseases affecting 3 million citizens operate without coordinated response frameworks (Bernal-Delgado et al., 2024). These omissions suggest that strategic planning responds more to advocacy and political visibility than systematic assessment of disease burden. Greece demonstrates particularly concerning strategic gaps, with no National Cancer Plan developed following the launch of Europe’s Beating Cancer Plan, combined with an absence of