PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025

71 Acting early on NCDs The Partnership for Health System Sustainability and Resilience7 Health system financing Financial flows shape every aspect of health system response to NCDs, determining what services are available, who can access them, and which interventions receive priority. Payment mechanisms create powerful incentives that either enable or obstruct prevention, early detection, and coordinated chronic disease management. For NCDs requiring sustained investment over long time horizons, financing arrangements fundamentally determine whether health systems can shift from reactive treatment to proactive prevention. This chapter examines how countries finance NCD prevention and care, analysing overall health expenditure patterns, prevention investment levels, financial protection mechanisms, provider payment models, and resource allocation formulas. It encompasses both public and private financing, direct and indirect costs, and the critical challenge of aligning financial incentives with the long-term, coordinated care that NCDs require. Health expenditure and prevention investment The aftermath of the COVID-19 pandemic and the ensuing economic slowdown resulted in significant adjustments in the health expenditure to GDP ratio. Data from the OECD suggests that by 2021, countries were spending 9.7% of their GDP on healthcare. However, less than 5% of this is allocated to prevention in all of the countries in our sample. The disconnect between the acknowledged cost-effectiveness of prevention and actual investment levels persists across all countries studied, revealing fundamental structural biases in healthcare financing systems. Germany’s approach illustrates this in relation to health promotion specifically: the report highlights that, since 2019, statutory health insurance funds have been mandated to allocate €7.52 per insured person annually for health promotion activities, a specific and measurable commitment. Yet this accounts for only 1.2% of total health expenditure from all financing sources, a share that has not grown between 2012 to 2022. Whilst Germany’s overall prevention expenditure is among the highest in Europe, the relatively small and static investment in health promotion reflects a broader tendency to prioritise treatment over upstream action. Spain allocates 3% of its healthcare budget to primary and secondary prevention, with the vast majority of resources continuing to flow toward hospital and specialist services (Bernal-Delgado et al., 2024). This allocation persists despite evidence that prevention offers superior return on investment, suggesting that budget processes respond to institutional power rather than effectiveness evidence. The concentration of resources in hospital care reflects both political visibility (hospitals are tangible symbols of healthcare investment) and professional influence, with specialist societies maintaining greater political weight than public health advocates. France dedicates only 2.3% to prevention, and within this limited allocation, over half (51%) is spent on disease monitoring at patient level, 20% goes to vaccination, 11% to early diagnosis, and 10% to health education and information campaigns, and 4% to population level surveillance. This distribution suggests that even within prevention budgets, resources flow toward activities that support the existing treatment-focused system rather than genuinely preventive interventions that might reduce future treatment demand. Greece represents an interesting exception that proves the rule about political will and prevention investment. The country increased prevention expenditure from 1.30% of current health expenditure in 2019 to 4.50% in 2022, surpassing the EU27 average of 4.30% (OECD/European Commission,