PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025

82 Acting early on NCDs The Partnership for Health System Sustainability and ResilienceGeographic maldistribution Geographic maldistribution amplifies quantitative imbalances, creating access barriers that disproportionately affect rural and remote populations with often higher NCD burden. Japan’s 1.8- fold difference in physician density between highest and lowest prefectures understates the problem, as specialist concentration in urban areas is even more extreme (MHLW, 2024i). Some rural prefectures lack entire specialties, forcing patients to travel hours or relocate temporarily for treatment. In Greece, over 60% of physicians practice in just two regions, Attica and Central Macedonia, leaving only 10% serving insular areas (Hellenic Statistical Authority, 2024; OECD, 2023a; OECD/European Commission, 2024b). This geographic concentration reflects powerful urbanisation forces: professional preferences for urban amenities, career opportunities concentrated in cities, educational institutions located in metropolitan areas that retain graduates, and dual-career households requiring employment opportunities for spouses. Poland shows dramatic urban-rural disparities, with Warsaw having physician density comparable to Western European capitals with over twice as many primary care facilities per 10,000 inhabitants compared to rural areas. The concentration of specialist training in major cities perpetuates this pattern, as it is increasingly difficult to attract residents who train in urban centres to rural practice. Rural areas also struggle to maintain the minimum patient volumes required for specialist practice viability, creating self-reinforcing cycles of workforce shortage (European Rural Development Fund Poland, 2022). Spain’s rural areas face particular challenges, with regions struggling to attract young healthcare workers as well as a pronounced rural-urban divide with limited specialist access due to workforce shortages and reluctance of specialists to practise in remote areas. Spain has introduced a range of incentive strategies to tackle workforce shortages in areas hardest hit. These include salary increases, ongoing training incentives, and job stability programmes, all designed to boost retention in the public healthcare system (Bernal-Delgado et al., 2024). Professional imbalances The imbalance between generalists and specialists compounds geographic disparities and directly undermines NCD prevention and management capacity. Primary care, which provides the optimal setting for chronic disease prevention, early detection, and coordinated management, faces critical shortages across all countries. Germany exemplifies the specialist-generalist imbalance afflicting many health systems. Despite having one of Europe’s highest specialist densities, it has the lowest GP density among neighbouring countries (OECD, 2023a). Only 35.9% of outpatient physicians worked in general practice in 2024, down from 37.6% in 2014 (KBV, 2024b). This reflects both the traditionally weaker gatekeeping role of GPs compared to other systems and the declining attractiveness of general practice (Wangler & Jansky, 2024). Average consultation times are under eight minutes, compared to 25 minutes in Scandinavian countries, severely limiting opportunities for meaningful preventive consultations essential for NCD management (Reif et al., 2023). The time pressure prevents comprehensive assessment, patient education, and the relationship building that underpins effective chronic disease management. Greece’s situation is particularly dire with merely 6% of physicians in general practice compared to the EU average of 21%, forcing patients to seek specialist care for conditions that could be managed more appropriately and cost-effectively in primary care settings. This creates system inefficiencies where expensive specialist resources are consumed for routine care whilst complex cases face delays. The absence of gatekeeping means specialists spend significant time on problems outside their expertise, reducing availability for cases genuinely requiring specialised input.