94 Acting early on NCDs The Partnership for Health System Sustainability and ResilienceRural populations face infrastructure barriers beyond individual digital literacy, for example unstable internet connections, which raise questions about clinical safety when digital systems fail. Even where infrastructure exists, the cost of devices and data plans may exceed limited budgets. The Spain report finds that the concept of digital inclusion is not yet fully integrated into health policies, highlighting that the European Commission has repeatedly warned that Spain needs to strengthen its digital inclusion programmes, especially for vulnerable, rural, and aging populations (European Commission, 2022), a finding echoed in several of the country reports. Research and innovation capacity Countries continue investing in research infrastructure whilst losing competitive position in global innovation networks, revealing structural challenges that financial investment alone cannot overcome. Declining research competitiveness Japan’s clinical trial ranking dropped precipitously from 4th to 14th globally over the past decade, with pharmaceutical companies’ global market share eroding relative to the USA and China (WHO GOHRD, 2024). This decline reflects structural factors beyond funding: slow healthcare digitalisation limits real-world evidence generation capabilities essential for modern drug development; linguistic barriers constrain participation in international trials and collaboration networks; bureaucratic approval processes delay study initiation by months, making Japan unattractive for time-sensitive trials. Creating unified governance would reduce redundancy, improve data quality, and accelerate evidence generation for both domestic and global therapeutic development. Spain maintains the 5th position globally with approximately 30,000 clinical trials conducted between 1999–2024, demonstrating substantial research infrastructure and scientific capability (WHO GOHRD, 2024). Yet this ranking masks deteriorating competitiveness: bureaucratic clinical trial approval processes significantly delay study initiation and increase costs compared to competing countries. Technology transfer offices struggle to bridge the gap between academic research and commercial development, with innovations often failing to progress beyond publication. Germany, despite hosting eight German Centres for Health Research dedicated to major NCD areas (including cancer, cardiovascular, diabetes, and lung diseases), has seen a relative decline in commercial clinical trial activity over the past decade, attributed to administrative delays, complex approval processes, and restrictive data protection rules (NIH, 2025; Nimptsch & Mansky, 2017; vfa, 2024). The 2024 Medical Research Act was adopted to accelerate trial approvals, introduce binding model contracts, and streamline regulatory oversight (BMG, 2023b). Unlike Scandinavian countries where unique identifiers enable dataset linkage, Germany prohibits cross-dataset identifiers, limiting secondary health data use. While the new Health Research Data Centre (FDZ Gesundheit) will consolidate statutory insurer billing data for research, health datasets largely remain siloed and difficult to access (Bundesinstitut für Arzneimittel und Medizinprodukte, 2025). Investment gaps and structural barriers These investments pale in comparison to leading research nations. The United States National Institutes of Health alone invests over $48 billion annually in medical research, more than 100 times Italy’s total commitment. Even adjusting for population and GDP differences, European investments remain fractional compared to global leaders. This funding gap reflects a fundamental challenge: countries recognise that domestic innovation capacity enables both economic development through life sciences sectors and health system advancement through locally-relevant research, yet commit resources insufficient to maintain competitive position.

PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025