PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025

77 Acting early on NCDs The Partnership for Health System Sustainability and Resilienceapproaches, and establishing evidence-based clinical pathways that guide patient journeys. Such reforms should be accompanied by payment mechanisms that, at minimum, avoid creating perverse incentives that fragment care or discourage coordination between providers and across care episodes. Resource allocation and territorial equity Most countries use formula-based allocation mechanisms that attempt to distribute resources based on population needs, but these formulas often fail to capture the complexity of NCD burden and the additional costs of serving disadvantaged populations. Simple age-weighted capitation formulas may account for demographic differences but miss the concentration of risk factors in deprived areas, the higher costs of engaging hard-to-reach populations, and the infrastructure deficits that require additional investment to achieve equivalent outcomes. Spain’s regional allocation system produces spending that ranges from €1,500 to €2,000 per capita across autonomous communities, variations that exceed what demographic and epidemiological differences would predict (Instituto Nacional de Estadística, 2021). However, wealthier regions benefit from stronger tax bases that enable supplementary spending, whilst poorer regions depend more heavily on central transfers that may not fully compensate for local resource constraints. Italy demonstrates how regional autonomy can exacerbate rather than address health inequities: more prosperous northern autonomous provinces allocate over €300 more per capita annually than southern regions, creating cumulative disadvantages in infrastructure, workforce, and service availability. Healthcare poverty rates, defined as a combination of economic burden of cancer care, travel burden, cultural and psychological barriers and systemic inequities (FAVO, 2024) in southern Italy reach 8%, twice the 4% rate in the northeast, with 22% of southern cancer patients travelling north for treatment, incurring substantial additional costs for travel, accommodation, and lost income. The national solidarity fund intended to address these disparities provides insufficient compensation, leaving southern regions structurally disadvantaged. These regional disparities create a form of “postal code lottery” where health outcomes depend as much on geography as on clinical need. However, significant inequalities can persist even in centralised health systems, suggesting that centralisation alone does not guarantee equity without additional mechanisms to address local needs and disparities. Canada’s federal transfer system helps support provincial health spending, but it does not eliminate differences across jurisdictions. The Canada Health Transfer provides equal per capita cash transfers that cover less than one-quarter of provincial health spending, with little adjustment for differences in population health needs (Marchildon et al., 2021). Provinces with stronger fiscal capacity can supplement federal transfers with their own revenues, while those with weaker capacity face greater difficulty maintaining comparable levels of service. This contributes to variation in coverage and access across the country. Urban-rural disparities Rural areas face systematic underfunding relative to the costs of service delivery, with formula- based allocations failing to account for the diseconomies of scale, travel requirements, and infrastructure needs of dispersed populations. For example, in Greece, resource allocation formulae do not take account of geographic disparities, despite the challenges faced by its dispersed island population in accessing care. Japan’s experience illustrates how standard allocation formulas disadvantage rural areas. Whilst urban areas benefit from economies of scale, rural areas face disparities in in access to basic services. The higher costs of attracting workforce to rural areas, maintaining equipment with lower utilisation rates, are not adequately reflected in payment rates based on urban costs. As a result, efforts are underway to optimise regional functional and resource allocation strategies (MHLW, 2024m).