PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025

6 Acting early on NCDs The Partnership for Health System Sustainability and Resilience■ Scale disease management programmes with systematic enrolment: Shift from voluntary participation to opt-out enrolment, ensuring programmes reach those most in need rather than just motivated volunteers. This must be combined with demand projections and corresponding capacity investment. Link programme funding to achieving both high coverage and quality outcomes that matter to patients, not just process measures. ■ Strengthen medication management for complex patients: Implement regular comprehensive medication reviews that consider all conditions together rather than disease-by-disease. Embed pharmacists within primary care multidisciplinary teams as active partners, with decision support tools identifying potentially harmful interactions and optimisation opportunities, particularly for older adults with polypharmacy. ■ Invest in structured self-management support: Develop programmes that go beyond information provision to build practical skills, with ongoing support systems helping patients navigate daily management challenges. Recognise self-management support as an essential clinical service requiring dedicated resources rather than an optional extra, including peer support networks and validated digital tools. ■ Build crisis-resilient chronic disease care: Establish explicit protocols for maintaining essential NCD services during emergencies, defining minimum service packages that must continue during disruptions. Develop remote management capabilities that can be rapidly activated, ensure supply chain resilience for essential medications, and incorporate lessons from COVID-19 into permanent preparedness plans. ■ Implement continuous quality improvement systems: Beyond developing guidelines, establish mechanisms ensuring implementation through regular audits with feedback to providers, support for improvement initiatives, and quality indicators reflecting patient outcomes rather than just process measures. Embed quality improvement in routine practice with continuous performance monitoring rather than treating it as an additional burden. System enablers Governance & accountability CURRENT LANDSCAPE: Japan’s structured approach with dedicated ministerial divisions and expert committees provides clear accountability lines, while Canada’s patient-oriented research networks successfully embed lived experience into policy design. However, fragmentation remains common across countries. Federal and regional systems create inconsistent coverage, national oversight often lacks enforcement powers, and cross-sectoral coordination on social determinants remains limited despite widespread recognition of their importance. Monitoring exists but rarely triggers corrective action: Italy’s documentation of extreme regional disparities has not produced effective interventions to address inequities. RECOMMENDATIONS: ■ Establish multi-sectoral coordination bodies with real authority: Create cross-ministerial bodies with clear mandates, adequate resources, and genuine budgetary authority to align policies across health, education, finance, agriculture, and urban planning sectors. These must move beyond advisory roles to have real influence over resource allocation and policy priorities, with formal accountability for achieving cross-sectoral objectives. ■ Develop comprehensive NCD registries for evidence-based decisions: Build integrated, interoperable systems tracking NCD incidence, risk factors, treatment patterns, and outcomes across the entire care continuum. This requires not only technical investment but governance frameworks mandating data sharing whilst protecting privacy, enabling systematic monitoring of progress and identification of gaps.