The wide range of NCD-related health challenges facing developing countries is fundamentally driven by a lack of targeted and sustained financing to prevent and combat chronic diseases, which in turn undermines human development and economic growth while driving inequality and high health care costs. Many countries’ health systems remain incapable of meeting essential needs, which impedes the prevention of NCDs. Changing the tide will require overcoming entrenched barriers to care by bolstering health infrastructure, upskilling and growing the health care workforce, expanding primary health care (PHC) services, adopting universal health care (UHC) as a guiding paradigm, and ensuring access to effective medications and therapeutics, among other efforts.  

This issue brief highlights priorities for health system strengthening globally, focusing on closing the NCD financing gap in the developing world through domestic resource mobilization (DRM) and more effective deployment of development assistance for health (DAH). Closing the NCD financing gap is made all the more urgent by the recent sharp downward trend in DAH, which could decrease significantly further in coming years. At the 78th World Health Assembly and looking ahead to the 4th UN High-Level Meeting on NCDs, stakeholders from across the public, private, and multilateral sectors have a shared imperative to critically examine the core impediments underlying the NCD financing gap and redouble efforts to strengthen health care systems in LMICs in order to meet and mitigate the NCD burden. Amid the pullback in DAH, cross-sectoral efforts that maximize the resources and expertise of a wide range of partners—from health care companies to international financial institutions to patient advocacy groups—will become all the more important. To course-correct on NCDs, there are accessible and affordable actions that national governments, international donors, multilateral institutions, industry, and civil society can pursue in collaboration, unlocking health and economic gains for diverse communities around the world.

Faced with high burdens and entrenched barriers, developing countries urgently need investment to counteract NCDs.

The health and economic impacts of NCDs are projected to intensify rapidly in the coming years, with the rising burden concentrated in developing states. The prevalence of CVDs—which include a range of disorders related to the heart and blood vessels, often leading to acute events like heart attacks and strokes—are expected to increase by 90 percent by 2050. Similarly, the prevalence of diabetes—a contributing risk factor for heart disease characterized by persistently high blood sugar levels—is expected to double by 2050, affecting 1.3 billion people. Often thought to predominantly affect wealthy countries, the NCD burden is rapidly growing in developing states. Whereas CVD deaths are expected to increase by 19 percent by the middle of the 21st century in high-income countries (HICs), they will increase by 190 percent in low-income countries (LICs) over the same time period. NCDs also levy high and long-term personal and economic costs, driven by premature mortality, living with a disability, and high out-of-pocket expenses. They additionally generate less-direct society-wide costs such as lost productivity, increased demands on family members and caregivers, and foregone education and professional opportunities. Between 2010 and 2030, NCDs are projected to cost the world economy USD 30 trillion. These costs make understanding and addressing the NCD burden an urgent global goal with multifold socioeconomic ramifications.

Health systems in LMICs face a nexus of overlapping challenges related to capacity, personnel, resources, and information that complicate mitigating and preventing NCD prevalence and mortality. Above all else, PHC is extremely limited, if not virtually nonexistent, for significant numbers of people in many LMICs, particularly LICs, where patients are often more likely to have access to some infectious disease care than the basic physical, mental, and social services that are essential for PHC. Both are critical to well-being. As of 2020, LICs had an average of just 0.3 physicians per 1,000 people, compared to 3.6 per 1,000 in HICs—or just one-twelfth of the reported availability in wealthy countries. More than 68 percent of those at high risk of diabetes in LICs report having no access to diabetes prevention or medical care, according to over 145,000 adults surveyed between 2009 and 2019. A host of problems contribute to this inadequate access to care, including limited health infrastructure, insufficient personnel or training, scarcity of available and affordable medication, fragmented care ecosystems, limited data collection and analysis, high out-of-pocket costs, lack of insurance coverage, weak policy implementation, low health literacy, and stigma and misinformation, among other impediments. Underlying all these challenges is a single fundamental driver: inadequate funding.

The scope of the NCD financing gap is significant and can be attributed to limited domestic fiscal capacity and lack of prioritization by country governments and international donors alike. Many LMICs have underdeveloped tax systems, which are shaped by informality and noncompliance and contribute to limited budgetary capacity. Likewise, many countries fail to recognize that investing in PHC can avert a range of health and economic costs that result from the growing NCD burden. Average annual per capita government expenditure on health was just USD 8.8 in LICs as of 2022, compared to USD 2,678 per capita in HICs. NCDs also represent a relatively low priority among external donors, who have historically devoted more resources to combatting infectious disease in developing states. Despite being responsible for 75 percent of deaths worldwide, NCDs have consistently accounted for around 2 percent or less of total DAH for the last two decades. As income level is closely correlated with access to quality health care, it is telling that the WHO’s Eastern Mediterranean, Southeast Asia, and Africa regions—collectively home to nearly four billion people and most of the world’s developing countries—account for just 5 percent of health spending worldwide. But while these countries face the brunt of the rising NCD burden, they also account for some of the greatest areas of opportunity for intervention.

Despite the daunting health and economic costs posed by NCDs, the world has a vast array of efficacious interventions at its fingertips, built upon strategies such as prevention, early detection, and chronic disease management. These policies and tools are not just effective at treating illness and lessening the suffering of patients, they are also frequently cost-effective, meaning the cost of implementation can be far outweighed by aggregate societal benefits. Return on investment (ROI) figures, which measure the anticipated value of benefits per unit of investment for a given intervention, provide a compelling case for increased prioritization of NCDs. The WHO’s Best Buys—which include basic preventative measures to counteract NCDs, such as reducing sugar, alcohol, and tobacco consumption and increasing physical activity—demonstrate an estimated ROI of 7 to 1, or USD 7 in society-wide benefits for every dollar invested. A 2022 study in The Lancet projected a higher potential 19 to 1 ROI for investing in a subset of the most cost-effective of these NCD interventions in LICs through 2030, including diabetes screening, alcohol and tobacco taxes, sodium reduction, pulmonary rehabilitation, and aspirin for suspected acute coronary syndrome. These substantial benefits stem from restored years of healthy life, averted medical costs, and improved economic productivity.

Proactive interventions that prevent and delay disease onset or enable early detection and treatment thus help to avert significant and varied costs, including monetary, time, stress, and other forms, for patients and society as a whole. Countering the growing NCD burden therefore depends on strengthening health systems across developing economies, including by increasing domestic spending on health care, targeting development assistance effectively, and attracting private-sector investment in innovation and partnerships to close the health finance and access gaps.

Domestic resource mobilization (DRM) is the lynchpin to health system strengthening and reversing NCD trends.

Governments will need to use a wide array of policy tools to mobilize resources and unlock efficiencies as they seek to reduce the burden of NCDs and build sustainable, effective domestic health care capacity in LMICs.

Key to mobilizing domestic resources to meet the NCD challenge are greater policy prioritization and communication among government stakeholders, including establishing NCD prevention, treatment, and care as part of either an NCD-specific action plan or a broader strategic health plan. Such plans ideally map out specific components of comprehensive NCD response (e.g., development of infrastructure and training of personnel) while tying each priority to specific budgetary needs over an extended time horizon, often five to ten years. The development of these long-term goals can aid productive relationships between ministries of health and government financiers, particularly when supported by detailed budgetary needs, anticipated benefits, and clearly defined goals with benchmarks and timelines. Kenya provides one such example of a fully costed NCD strategic plan, which allocates KES 377 billion to NCDs over 2021 to 2025, including 42.2 percent budgeted specifically for CVDs and diabetes care and prevention. As countries seek to develop comprehensive and effective action plans, they can look to the UN Development Programme’s guidance on developing context-specific investment cases based on local burden, expected costs, potential impacts of care, and anticipated ROI. Such long-term planning can help build the structures and drive the political momentum necessary to raise and commit additional funds for treating NCDs, likewise serving as a signal to external parties, public and private, of government buy-in to the health sector.

In order to enact broader NCD policies, national governments will need to dedicate tax revenue to increase fiscal resources for health spending and provide the foundation for collective insurance schemes that are critical to eliminating high out-of-pocket costs and instantiating UHC. While elements of tax reform, such as formalizing the economy or cracking down on noncompliance, will require economy-wide reform not immediately related to the health sector, there are potent health-related taxation policies that can return compounding benefits. Health taxes, for example, can be deployed to target unwanted behaviors such as alcohol, sugar, and tobacco consumption, providing the dual benefit of raising government income while deterring risk factors that drive NCDs. Such taxes have proven effective in LMICs such as the Philippines, which began deploying health taxes in 2012 and earmarking revenues to support its country-wide UHC scheme, PhilHealth. A tax introduced on sugary beverages in 2018, for instance, is projected to generate USD 627 million in health savings over its first two decades while raising an average of USD 813 million in government revenue annually. By 2022, government subsidies to PhilHealth were five times higher than in 2013. Earmarking—or assigning a revenue stream to a specific end goal—is widely used to fund social health insurance schemes, particularly through payroll taxes, and is a key step to building up a foundation for UHC and ensuring access to health care across underserved populations.  

Particularly amid the ongoing pullback in international funding for global health, country governments need to take advantage of potential areas of overlap between infectious disease and NCD goals and getting the most out of extant health care capacity. In many of the world’s least-developed countries, infectious disease care can often be more readily available than PHC. To help meet the demand for expanding PHC, infectious disease capacity can be repurposed, or its remit expanded, to provide basic services, such as blood pressure and blood sugar monitoring. Countries can also utilize infectious disease spending to strengthen basic health services over the long term. For example, during the 2000s and 2010s, Rwanda deployed disease-specific funding from PEPFAR and the Global Fund to strengthen health infrastructure and primary care, ultimately contributing to the PHC capacity that undergirds the country’s current UHC scheme, Mutuelles de Santé. Infectious disease and NCD health capacity can also benefit from greater integration, both from a clinical perspective as well as in the search for potential synergies and cost-savings. Strategic coordination, for example, can permit broader health sectors to pool demand for essential medical goods and equipment, thereby improving economies of scale and providing a stronger bargaining position for procurement.

Sustainably counteracting and treating NCDs ultimately depends on mobilizing domestic resources, but the scarcity of fiscal resources in many countries remains a substantial impediment. Even as some donor countries pull back from development assistance, it is worth highlighting the opportunities for catalytic investment by external public and private partners. They cannot bear the majority of the costs of NCDs, but they can be impactful, working in tandem with governments, to drive health system development, address public health crises, and build healthier, more resilient communities.

Development assistance for health (DAH)—composed of external government, private-sector, and philanthropic investment—plays an essential role in counteracting NCDs.

Despite being the cause of three in four deaths globally and the source of rapidly rising mortality and health costs in the developing world, NCDs are rarely the target of official development assistance from wealthy countries. Countries within the Organisation for Economic Cooperation and Development (OECD), which includes most major donors of development assistance globally, devote less than one percent of total DAH specifically to treating NCDs.

To maximize impact, external partners seeking to expand DAH must ensure that aid more accurately reflects the burden posed by NCDs and target their contributions toward health system strengthening and building up DRM, especially as it pertains to providing essential PHC services and further establishing UHC. Above all, the bulk of these investments need to prioritize programming that contributes to the development of sustained capacity, which can take many forms. The Australian-supported RESist-NCD partnership in Cambodia, Fiji, Papua New Guinea, the Philippines, and Vietnam supports integration of hypertension and diabetes services into PHC, including through policy and taxation initiatives, with the ultimate goal of developing national implementation plans.

Even while seeking out programs with high-returns and sustained impact, DAH also needs to be leveraged to save lives at high risk where governments are incapable or unwilling to meet the needs of marginalized groups, even if these investments do not contribute to strengthening health systems. In the case of protracted conflict and displacement in Syria over the last 15 years, groups like the International Rescue Committee, funded by the European Union, helped provide life-saving access to insulin for the estimated 1.8 million Syrians living with diabetes, working to bridge a gap in critical NCD care until in-country health systems can be restored. This work can also include programming to target marginalized or under-resourced groups, as the Reach Out Mbuya program in Uganda does by bringing integrated HIV/AIDS and NCD care to some 7,000 of Kampala’s urban poor. Public and private stakeholders cannot afford to ignore the life-saving potential of health investments, particularly when temporary interventions hold great potential to save lives, mitigate acute vulnerability, and prevent significant economic hardship.

Because NCDs pose a whole-of-society challenge, they warrant cross-sectoral responses, blending the strengths of partners across national and local governments, health care providers, pharmaceutical companies, academia, insurers, civil society, patient advocates, and beyond. Particularly as major government donors such as the United States pull back, the private sector has a critical role as a source of knowledge and funding and a catalyst of innovation and change. NCDs pose a complex, long-lasting challenge, with patients frequently facing decades of illness requiring countless points of contact with health providers across their communities. Chronic disease management, such as with CVDs and diabetes, requires a network of partners, harnessing the capabilities and strengths of each.

Public-private partnerships (PPPs) have demonstrated capacity to deploy private sector dollars and expertise to tackle public, even global problems. The Transform Health Fund, an impact fund by AfricInvest and the Health Finance Coalition, raised over USD 111 million as of 2024 to invest in improving health care systems and models across Africa. Alongside partners like the International Finance Corporation, Swedfund, and the Skoll Foundation, the fund is investing in local partners like the Africa Healthcare Network, a leading, Africa-based dialysis provider. Blended finance mechanisms also help to derisk the health sector, making it more attractive to private investment and making public contributions go further. The African Health Diagnostics Platform, co-funded by the Gates Foundation and the European Investment Bank, seeks to improve data on NCD prevalence across sub-Saharan Africa and demonstrates possible impact when combining public and private resources to support health programming with long-term benefits. Moving forward, innovative, cross-sectoral approaches to health funding, such as deploying social impact bonds and divesting from harmful industries, can help expand the private sector’s impact on NCD outcomes, strengthening its role in confronting a global challenge.

Finally, as international stakeholders, both public and private, seek to maximize impact and tackle a range of overlapping global priorities—be they infectious disease and NCDs or broader goals like health, climate, and development—it is worth reiterating the close linkages among adjacent development goals. Sustained progress in any of these issue areas, to some degree, is predicated on making progress across the others. In the nexus between climate and health, for instance, climate change exacerbates illnesses such as CVDs through rising temperatures, extreme heat, and disruption of routine medical care, while the health care industry itself exacerbates climate change, accounting for as much as 5 percent of global emissions. Similarly, efforts to eliminate extreme poverty will be at a disadvantage as long as the high costs of NCDs go unmitigated. As a result, NCDs need to be clearly identified as an inseparable component of parallel development agendas at international fora such as the UN General Assembly, G20, COP30, and regional summits to drive action and investment toward programming with multifaceted, complementary benefits.

Neglecting investments in NCDs today will cost lives and livelihoods tomorrow.

NCDs are responsible for roughly three-quarters of all deaths annually, more than 40 percent of which occur prematurely, yet these diseases remain underprioritized within domestic and international health care strategies. LMICs in particular stand to suffer significantly in the years ahead, as lack of health care capacity and exploding population growth will put millions at risk of prolonged illness, disability, and death. To address this rising burden, stakeholders should consider targeted action to reduce and close the NCD financing gap—setting the path toward more developed, resilient health systems across the developing world.

Several cross-cutting recommendations can help direct these efforts:

• Prioritize domestic resource mobilization (DRM) to encourage long-term fiscal sustainability and capacity strengthening. Long-lasting, community-centered care will necessarily rely on increasing tax revenue, earmarking funds for NCD programming and primary health care (PHC), deploying social health insurance systems, and ensuring government buy-in through long-term policy plans and clear investment cases.
• Increase development assistance for health (DAH), particularly with a focus on NCDs. Even before the recent pullback from development assistance in some Western countries, such as the United States and United Kingdom, the very limited proportion of official development assistance that targeted health was not commensurate with unmet needs and the immense costs posed by illness globally—and NCDs in particular. DAH alone is not a long-term solution to health care provision, but it can be a powerful catalyst for health system strengthening and a critical lifeline for underserved populations, especially in times of crisis.
• Encourage cooperation among public, multilateral, private, and non-profit entities to build resolute networks capable of problem-solving and persistence. The scope of the NCD challenge and the chronicity of many diseases necessitate a whole-of-society response. Governments can provide clear and sustained policy guidance, the private sector can offer innovation and investment, and civil society can help connect public- and private-sector partners with patients and caregivers in communities. Ensuring affordable access to NCD care across the life course will require this range of stakeholders to work in collaboration.
• Seek out mutually beneficial areas for action among adjacent health, economic, and climate goals. Health must be persistently highlighted as a foundational component of other major development agendas, from climate resiliency to the elimination of extreme poverty. Global, regional, and domestic development agendas will be more effective if they can be mindful of, and capitalize on, these close relationships.
• Improve data collection and analysis, particularly as relevant to early screening and diagnosis as well as development of compelling investment cases. Many developing states continue to operate in relative darkness in terms of patient data, leaving policymakers and health providers essentially “flying blind.” Improved data collection and research in LMIC contexts, including expanding clinical trials on CVDs, tracking the evolving needs of at-risk populations, and sharing best practices on prevention and treatment are all critical to developing compelling investment cases to drive change and mitigate the NCD burden. This work represents a fruitful area for collaboration among governments, the private sector, and multilateral institutions.

By Phillip Meylan (Affiliate Researcher). Illustration by Adrián Astorgano.

This issue brief was produced by FP Analytics, the independent research division of The FP Group, with support from Sanofi. FP Analytics retained control of the research direction and findings of this issue brief. Foreign Policy’s editorial team was not involved in the creation of this content.