Non-communicable diseases (NCDs), also known as chronic diseases, are a globally increasing concern for national governments and society due to their high mortality and morbidity (1, 2). These medical conditions are associated with slow progress and long durations (2). According to the World Health Organization (WHO), they are the leading cause of deaths worldwide (2), accounting for 86% of mortality and 77% of disease burden in WHO European Regions (1). By 2030, NCDs' total number of deaths will rise to 55 million, according to the WHO's projection, if nothing changes. Cardiovascular diseases (CVDs), cancers, chronic respiratory diseases, and diabetes are the top 4 causes of premature mortality among NCDs (2). Nevertheless, people live longer with disabilities resulting from chronic diseases, as premature mortality reduces. Multimorbidity affects 65% of people over 65 years, requiring more patient-centered and complex care models (3).

NCDs are also responsible for growing health inequalities observed in many countries, demonstrating socio-economic gradient and gender differences; e.g., European women live approximately 8 years longer than men (4). NCDs result from several factors, e.g., behavioral, environmental, genetic, and physiological factors (2). They share 4 main behavioral risk factors: unhealthy diet, tobacco, harmful use of alcohol, and physical inactivity (4). Apart from the behavioral health determinants, living conditions, such as poverty or housing conditions, play an essential role in developing NCDs (5). Education is a key factor influencing health because it is related to health literacy and consequently to health behavior and influences labor market opportunities, income (poverty), and other living conditions (5).

Cost-effective curative and preventive action can significantly reduce NCD burden, along with already available NCD control and preventive interventions (4). However, NCDs and their challenges cannot be dealt within the health sector alone. New health policies are required to develop national integrated strategies for NCD control and prevention (6). Globally, a number of documents exist concerning NCD prevention and management on a strategic level. Key documents are the WHO Global Action Plan for the Prevention and Control of NCDs (4) and the Action Plan for the Prevention and Control of NCDs in the WHO European Region 2016–2025 (5). Additionally, individual countries develop multisectoral, comprehensive NCD control and prevention policies. A systematic policy analysis by Briggs et al. evaluated health policies for integrated prevention and management of NCDs among the Member States of the OECD (Organization for Economic Co-operation and Development), focusing on their aims and strategies to achieve these aims as well as evaluating the integration of musculoskeletal conditions. The analysis including 44 policies from 30 OECD Member States found that the policies of most countries covered cancer (83%), diabetes/endocrine disorders (77%), CVDs (77%), mental health conditions (63%), respiratory conditions (63%) and musculoskeletal health and pain (50%). Almost all policies (96%) outlined general strategies (7).

Based on the analysis of Briggs et al., we are extending the analysis by not only including strategies concerning NCDs in general but also considering strategies focussing on single NCDs. This paper, therefore, aims to provide an overview of the latest status of national strategies for preventing and managing selected NCDs (CVDs, chronic respiratory diseases, diabetes type II, depression) in selected (Western high-income) countries and their implementation.

We will further address knowledge gaps concerning the implementation of the strategies and the specific programs and interventions planned to be carried out in order to reach the respective aims of the strategy.

The following research questions will be answered: (i) Which national strategies/policies (at a macro level) are in place in Western high-income countries concerning the aforementioned NCDs and their risk factors, and what are their main objectives and features? (ii) What information is available on the implementation stage and implementation process of those strategies?

This article aimed to provide an overview of national strategies for preventing and managing NCDs in selected countries. We included 4 NCDs, which are CVDs, chronic respiratory diseases, diabetes type II and depression. We searched for national strategies in various databases and selected 8 countries and their strategies (n = 18). Main characteristics and implementation process information from the 18 included strategies were extracted.

Most of the strategies provide information on prevention and disease management and formulate rather broad overarching aims or visions (e.g., “stay healthy” or “living healthier lives”) as well as more specific targets that differ across strategies. The strategies were developed for short to intermediate time frames from 2 to a maximum of 10 years. A range of different stakeholders are involved in the development and/or implementation of the strategies, e.g., ministries, health care providers, patients and the civil society, health insurances, as well as research institutions. All analyzed strategies include information on their planned monitoring and evaluation processes. Information on funding is heterogeneous and usually does not go into detail. All of the included strategies provide information on the measures and activities planned to be carried out within the implementation of the strategy, usually structured according to the respective targets, strategic directions or fields of action.

The analysis of the national strategies showed that the degree of organization of the identified strategies and policies differed considerably between the countries. The most elaborated and structured strategy is the Swiss NCD strategy. As part of the Health2020 strategy³, the “National Strategy for the Prevention of Non-communicable Diseases 2017–2024” (18) was presented in 2016. The NCD strategy includes actions in 3 main areas: population-related health promotion and prevention, prevention in health care, and prevention in the economy and the world of work. All measures to be carried out within the implementation of the strategy can be found in the associated action plan (27). Regarding monitoring and evaluation, Switzerland also provides detailed information on the indicators to be used as the basis for an NCD monitoring system (28) and has already published an interim evaluation report (29) as well as annual reports.

Other countries, however, do not provide such detailed information on concrete activities and the implementation process. Some strategies remain rather superficial without mentioning specific measures to be carried out to reach the strategy's aims. For some countries, we could not identify any NCD strategies at all. For example, this was the case for Sweden. Sweden does not have an overall strategy for NCDs, but the work with alcohol, tobacco, eating habits and physical activity is instead included in various governing documents.⁴ A comparison across the EU Member States shows that Sweden has the highest healthy life years at birth, with 74 years for men (30). This demonstrates that there may be a number of different successful approaches for tackling NCDs on a strategic level and not a one-size fits all method.

In 2013, the ‘WHO Global Action Plan for the Prevention and Control of NCDs 2013–2020' was endorsed by the World Health Assembly. This plan provides the WHO, international partners and Member States with a menu and road map of policy options, including 9 global NCD targets (4). Next to global strategies, regional strategies, such as the “Action Plan for the Prevention and Control of NCDs in the WHO European Region 2016–2025” (3), and national and sub-national strategies exist. However, a report of the UN High-level Meeting on the Prevention and Control of NCDs in 2018 stated that many countries are lagging behind these aims, although lots of proven interventions for NCDs exist (31). In the article of Briggs et al., only one-third of the included 44 policies were explicitly aligned with the WHO global action plan (7). This is in line with our findings: The majority of the included strategies in this paper provide no information concerning the alignment with the WHO global action plan; nearly one-third of this article's strategies were explicitly linked. This is despite the fact that all WHO Member States have decided on the WHO global action plan. While national strategies must naturally reflect local situations, one would still expect to see that the national strategies would follow the WHO strategies and action plan to a certain extent. However, there are other action plans commissioned by the WHO that may be relevant for disease-specific strategies, such as the WHO Mental Health Action Plan 2013–2020 (32), which was mentioned by the Australian strategy on mental health (14).

The 3 key themes to describe the general aims of NCD strategies identified in the study by Briggs et al. (7), analyzing NCD policies among OECD member states, were better population health, improved service delivery and system-strengthening approaches (such as implementing models of care). Our results also reflected these findings regarding the topics of strategies' aims, e.g., “improving health in general”, or “strengthening coordinated services and integrated care.” However, we identified some further themes such as improvement of self-management, empowerment and health literacy, and reducing health inequalities.

The included strategies address NCD prevention and management from a cross-sectoral “Health in All Policies” approach that goes beyond measures within the health care system. Examples are structural prevention activities concerning nutrition, creating physical activity-friendly urban areas or increasing (mental) health literacy in education and the workplace. The Swiss NCD strategy, for example, explicitly refers to the Model of Health Determinants by (33), including socio-economic, cultural and environmental conditions, living and working conditions (such as housing, work environment, unemployment, education), social and community networks, or individual lifestyle factors (18).

11 of the 18 strategies explicitly stated that patients and/or “the public” were involved in developing the strategy as stakeholders. For developing own strategies, more detailed information on the methods of patient involvement will be necessary in order to guarantee representativeness and well-designed involvement processes. Furthermore, it is noticeable that out of 18 strategies, only a minority mentioned academic institutions, civil society or commercial players as stakeholders, although the involvement of as many stakeholders as possible is crucial for comprehensive national action and successful NCD prevention.

Our analysis of the strategies focussed on adults; however, especially in preventing NCDs, a life course approach is helpful to consider all age groups' needs and address NCD prevention and control in its earliest stages (34). Additionally, a life course approach is crucial to tackling inequalities of health, i.e., the unequal conditions in which people are born, grow, live, work, and age, as well as the inequities in power, money, and resources (35). Importantly, health promotion and prevention in early childhood (especially regarding mental health) have been shown to be particularly promising regarding return on investment (36). An alternative to the involvement of children and adolescents in general NCD strategies would be to develop specific strategic plans for their wellbeing as already implemented in some countries.

We included strategies dealing with one or more of 4 NCDs – CVDs, chronic respiratory diseases, diabetes and depression. Other high-burden NCDs, such as cancer or musculoskeletal conditions, were not the focus of this paper, and we, therefore, cannot provide information on those disease areas. The Austrian Ministry was interested in strategies of other countries to develop, improve or adapt Austrian strategies. Cancer, for example, although the second cause of mortality, was not considered because Austria already applies a comprehensive National Cancer Strategy [Krebsrahmenprogramm Österreich].

Furthermore, some countries (e.g., Sweden) do not have specific NCD prevention strategies but instead have legislation, strategies or policies on risk factors such as tobacco and alcohol control, dietary and physical activity policies, or obesity prevention. These components of NCD prevention are not specifically included in the present analyses, which are therefore limited in giving a full overview of all country activities.

We searched for national NCD strategies and policies using a structured and extensive hand search. We did not perform a systematic literature search in databases because national strategies are often published on websites, e.g., of the respective Ministry of Health. As we did an online search for national strategies, we may have missed strategies not published online. Furthermore, the focus of this article was on governmental strategies and, therefore, other strategies (e.g., issued by non-governmental organizations) are not included.

Another limitation is that some countries only provide strategies in their national language. As we could only include documents in English or German, we had to exclude strategies that were not available in one of these languages. However, we included a broad range of countries with different public health traditions and health systems, focusing on Europe but also involving 2 non-European countries.

We did not address all types of characteristics in the strategies. Regarding the objectives and aims of the included strategies, further interesting aspects would be the time horizon (i.e., short-term, intermediate, long-term) and the quality of these aims, i.e., if they can be considered as SMART (specific, measurable, achievable, realistic, time-bound) (37). These may additionally be considered when developing a new strategy.

It is well-known that the implementation gap is usually an issue, and the actual implementation of national strategies matters for national NCD prevention. Fortunately, the implementation of WHO-recommended NCD policies is increasing over time. However, on average, only less than half of the NCD policies recommended by WHO were implemented of the 151 evaluated countries in 2017 (38).

Despite the aforementioned limitations, the results provide a valid overview of the heterogeneity but also common themes across national strategies of different countries in preventing and managing NCDs.

We can derive some actionable recommendations for the development and implementation of national strategies: Firstly, strategies may consider a life-cycle approach and particularly include aims addressing prevention of NCDs in children and adolescents because of the long-term preventive potential.

Many important factors influencing the population's health are beyond individual biological factors (age, gender, genetic factors) and lie outside the health care system, such as in the area of social, educational, environmental, labor market, transport or economic policy. Those should be addressed in the strategies by a “Health in All Policies” approach (39). Not addressing those determinants and the structural prevention approaches entails the risk of reinforcing health inequalities.

Finally, a structured approach of strategies from a macro to a micro level seems crucial to achieving a comprehensive, coordinated overall policy. Strategies need to be regularly evaluated using appropriate methods to measure target achievement. Additionally, implementation parameters need to be sufficiently addressed, and evaluation designs need to be developed before strategies' implementation.

To conclude, many Western countries apply national strategies and policies dealing with NCDs' prevention and/or management. These differ substantially in terms of their level of detail, structure and implementation. The strategies mainly aim at preventing NCDs, improving health and quality of life, strengthening self-management and health literacy, reducing health inequalities, and providing integrated care and coordinated services for chronic conditions. All strategies include information on specific actions and activities to be carried out to reach the aims, but only some strategies give detailed information on these programs and interventions, including their evaluation.

LG and IR searched for and selected the strategies and extracted, analysed, and interpreted the data. LG wrote the first draft, which all authors revised critically for important intellectual content. All authors contributed to the conception and design of the work, read, and approved the final manuscript.

This study was supported by the Publication Fund of the University of Vienna.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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