73 Acting early on NCDs The Partnership for Health System Sustainability and ResilienceGreece faces the most severe challenges among studied countries, with 33% of health spending coming from out-of-pocket payments, among the highest proportions in Europe and a level that fundamentally undermines the principle of universal coverage (OECD/European Observatory on Health Systems and Policies, 2023b). The impact is starkly differentiated by income: 23% of the poorest quintile forgo necessary care due to cost compared to only 3.4% of the wealthiest quintile. The poorest households spend 9.0% of their total household expenses on medications alone, versus 2.7% for the wealthiest households. Most alarmingly, catastrophic health expenditure, defined as spending that threatens household financial stability, rose from 6.44% to 22.24% for Greece’s poorest households between 2007 and 2015, a period coinciding with economic crisis and austerity measures that reduced public health coverage. Italy recorded €40.6 billion in total household out-of-pocket expenditure in 2023 (ISTAT, 2024), showing steady annual increases that consistently outpace income growth, gradually eroding the financial protection that universal coverage is meant to provide. The phenomenon of “financial toxicity” documented in Italy, where patients experiencing financial hardship face 1.2 times greater mortality risk (FAVO, 2024), demonstrates how economic barriers translate directly into health outcomes through delayed care, medication non-adherence, and foregone treatments. Canada illustrates how the design of benefits packages affects access to NCD care, with deep coverage for physician and hospital services contrasting sharply with limited coverage for pharmaceuticals and allied health services (Marchildon et al., 2021; PHAC, 2021) which constitute major components of NCD prevention and treatment. These gaps create particular hardship for people with chronic conditions. For example, in 2023, more than half of Canadians with type 1 diabetes, and many with type 2, either spent over 3% of their household income on care or were unable to follow their doctors’ treatment recommendations because of costs (Diabetes Canada, 2023). Such shortfalls in pharmaceutical coverage force patients to make difficult trade-offs between adherence and financial stability. Figure 16: Government/compulsory and out-of-pocket healthcare expenditure as a share of GDP , 2022 (or nearest year) Note: * = OECD estimate for 2022. Source: OECD, 2023a. 10.910.39.88.07.36.85.15.0 1.71.81.73.23.12.23.51.7 12.712.111.511.210.49.08.66.7 GermanyFrance*Japan*CanadaSpain*ItalyGreece*Poland Government/Compulsory Voluntary/Out-of-pocket Total

PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025